The Clerkship Guide

7/24/2019 The Clerkship Guide

http://slidepdf.com/reader/full/the-clerkship-guide 1/219

HE

Clerkship Guide

he unofficial UBC Medical School survival

guide to third and fourth year

Leslie Anderson Andy ChenMaggie Eddy Aaron Gropper Christine ang

!esign" Chanel #ok



ABLE $% C$& E& S

Contri'utors((( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( )

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Ho# to $perate in Surgery(((( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( 02

*ellness((( (( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 10

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/ The CLE8SH74 GU7!E ; Ta'le of contents





*ELC$ME $

,8! -EA8.

*ritten 'y Leslie Anderson< M! /6),

Edited 'y Andre# *ong< M! /6)0

This year is #hat youDve 'een #aiting for ? to 'e in the hospitals and clinics#orking directly #ith patients as a useful part of the health care tea+( -oupro'a'ly #onDt %EEL useful at first< 'ut rest assured that as the year goes on< you

#ill 'eco+e +ore and +ore co+forta'le #ith your role and #ill 'e contri'utingin an increasingly +eaningful #ay( The learning curve starts out steep< 'ut trustus< things #ill start to stick( -ouDll start to develop your o#n #ay of approachingtasks and your o#n style of +edicine( Hopefully< you #ill also find that +agicalspecialty to fall in love #ith if you havenDt already.

As youDve heard< third year is going to 'e a challenge( The hours are long and youneed to find ti+e to study for the ea+s that co+e up every fe# #eeks( So+e+ornings #ill start really early #hile others can end Fuite late( Be prepared tospend up to /2 hours straight #orking a call shift( -ou +ay also co+e up againstdifficult +o+ents #ith patients or colleagues< or +ake +istakes that +ake you

feel stupid< and youDll pro'a'ly have days #here you co+e ho+e< 'urst into tears<and #onder #hy you ever thought going into +edicine #as a good idea(((((

But< thatDs okay. *eDve all 'een there( 7tDs tough( But itDs also re#arding<interesting< and a+aing( -ouDll get to #atch peristalsis happen 'efore your eyesin general surgery( -ouDll learn to figure out #hatDs causing your patientDsacidosis( -ouDll offer co+fort to people that are 'reaking do#n fro+ their o#nfrightening health?related eperiences( This year is -$U8 chance to >u+p in andtry it all #hile you have a+ple support 'acking you up< to 'eco+e the 'est docyou can possi'ly 'e( So #hen it see+s like all the odds are stacked against you

and the #alls are caving in< focus on all the great things youDve seen plus thea#eso+e #ork youDve acco+plished and plo# right on through.

This guide #as created 'y the Class of /6), in the hopes that #e can +ake Third-ear a little less inti+idating(

Good luck< and hang in there.

/ The CLE8SH74 GU7!E ; *elco+e to ,rd -ear.



A special note to the 'rilliant students studying outside 3%M4" Although#e did our 'est to all infor+ation regarding UBC Clerkship< #e #ereuna'le to gather so+e specific infor+ation for sites outside of the 3%M4(-ou have not 'een forgotten. *e are #orking hard to +ake sure that thisinfor+ation is included in the net edition of the clerkship guide( Becauseall of the infor+ation co+es fro+ students< if you are studying in

Chilli#ack or elo#na or 3ictoria or any#here outside of the 3%M4< #e#elco+e your advice.

, The CLE8SH74 GU7!E ; *elco+e to ,rd -ear.



HE BAS7CS

*ritten 'y Leslie Anderson and Andy Chen< M! /6),

Edited 'y Andre# *ong and !iana ang< M! /6)0

Ho# to choose and rank your track(((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( :

3alua'le pearls fro+ )st and /nd(((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 5

*hat third years #ished they kne#(((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 2

Ho# to prepare for clerkship((( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (

Best clerkship s+artphone apps((( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ()/

Ho# to study during clerkship((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ),

7s a car necessaryI((( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( )0

7+portant pearls of advice((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ):

: things to take %ULL advantage of .(( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( )5

en +o+ents that #ill happen in ,rd year((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ()

0 The CLE8SH74 GU7!E ; The Basics



Ho# to choose and rank

your track

There are lots of different schools of thought #hen it co+es to deciding #hich tracks to rankhighest( Generally< people are happy #ith #hat they get< regardless of the order the rotations fallinto< and things #ork out in the end( But< there are a fe# things one could consider #hen rankingtrack choices(

The 'iggest decision tends to 'e #hether to do the JBig ,K @internal +edicine< surgery< andpediatrics< #hich are 2 #eeks each first or last( Here a fe# things to ponder as you +ake that+a>or choice"

B7G , %78S " 48$S

-ou get the+ over #ith. $h 'a'y. There is a #ave of relief and +uch less stress after thehalf#ay point.

Usually students are keen and fresh at the 'eginning of the year< +eaning they have +oreenergy for these intense and long rotations(

!oing 'oth +edicine and surgery early can help you figure out #hich u+'rella of specialtyyou fit 'est under if youDre still not sure(

-ou get a great< 'road 'ackground to help you in the other rotations( &othing feels scary orforeign after youDve learned ho# to consult patients< ad+it the+< and +anage the #ards(

The long duration of the rotations allo#s you ti+e to figure out ho# the hospital #orksand #here everything is at the +a>or hospital sites and still have ti+e to get a lot out of therotation< #hereas if you start #ith a rotation that is one or t#o #eeks long< youDd #aste alot of ti+e >ust figuring out #hat to do(

B7G , LAS " 48$S

-ou get to #ork up to the 'ig rotations instead of >u+ping right in< #hich +eans youDll feel+ore prepared and less over#hel+ed( -ou can use the first half of the year to study inpreparation for the 'ig ,(

Starting #ith the s+aller rotations allo#s you to eplore +ore options 'efore 0th yearelectives need to 'e chosen(

-ouDll 'e doing the 'ig , during the longest hours of su++er #hich +eans you #ake uprefreshed to the sunlight and possi'ly leave the hospital #ith sunlight< so you can still en>oyso+e of the evening outside(

: The CLE8SH74 GU7!E ; The Basics



A %E* $ HE8 H7&GS $ EE4 7& M7&!

7f you have a good idea of #hat youDd like to do< +ost students reco++end ai+ing for atrack that puts that rotation +id#ay through the year( That #ay< you have enougheperience on the #ards to +ake you look good< 'ut itDs also early enough that if youdiscover you donDt like it as +uch as you thought< thereDs lots of ti+e to change your 0thyear electives(

!oing internal +edicine 'efore surgery can 'e very helpful< since the #ritten ea+ forsurgery tends to involve +any internal +edicine topics(

The learning curve on your first rotation #ill 'e Fuite steep as you figure out #hat youDreepected to do< ho# the #ards #ork< ho# to #rite orders< etc( so you +ight #ant to start#ith so+ething you kno# you have no interest in( That #ay< you #onDt 'e as stressed out ifyou +ess up a lot.

7f youDre trying to decide 'et#een a couple of specialties< doing the+ earlier in the year #illhelp you figure out #hich direction you #ant to go in 'efore itDs ti+e to choose 0th yearelectives(

$'sGyn can 'e a difficult and tiring rotation @essentially +aking it J'ig 0K< so so+estudents decide they prefer to keep this separate fro+ the 'ig , to have a 'it of a 'reak @e(tracks BC

8eturn to"a'le of Contents




3alua'le pearls fro+ )st and /nd

year to take into ,rd year

-our physical ea+ and history skills are crucial ? +any ti+es< your assess+ent #ill 'etrusted as accurate and #onDt 'e redone 'y a resident or attending< so +ake sure you kno##hat youDre doing( Having said that< ho#ever< +ake sure you al#ays ad+it #hen you donDtkno# so+ething< or if you forgot to ask or ea+ine so+ething( &ever +ake upinfor+ation.

Having an approach to pro'le+s is very helpful( 7n 4BL< you use 37&!7CATE and thatapproach can 'e applied to pretty +uch anything< 'ut as you go along< youDll pick up otherapproaches as #ell( So+eti+es itDs helpful to go 'y syste+s @such as in chest pain< #hileother pro'le+s reFuire a +ore anato+ical approach @like a'do+inal pain( *hatever you

end up using< having a good approach that +akes sense to -$U is key. -ou #ill #rite S$A4 notes every day< so +ake sure you understand ho# to #rite the+ #ell

@see the J!ocu+entationK section(

Anti'iotics #ill 'e used in al+ost every rotation( no#ing #hich ones are +ost co++onlyused for the +a>or issues @pneu+onia< UT7s< skin infections< +eningitis< preoperative along#ith the +ost co++on 'ugs that youDre targeting in those infections #ill 'e very handy(

Have an approach to chest ?rays and ECGs< as you #ill encounter a lot of the+.

4rofessionalis+ is i+portant( Make sure to carry for#ard the ha'its you developed inClinical Skills ? dress appropriately< treat people #ith respect< sho# up on ti+e( Theprinciples are si+ple 'ut they +ake a 'ig difference(

$verall< re+e+'er that you have learned #ell and kno# your stuff( -ou #ill 'e fine.

8eturn to" a'le of Contents




!onDt +iss" *hat third years

#ished they kne# going into

Clerkship

7tDs okay to not kno# things( The #hole point of ,rd year is to learn ? if you already kne#everything< you #ouldnDt need to 'e here.

4retty +uch everyone feels like they failed the &BME #ritten ea+s< 'ut virtuallyeveryone still passes(

Let the attending physicians and residents kno# #hat level youDre at and #hat point of theyear youDre in< 'ecause they donDt al#ays kno# and if they realie that youDre >ust starting

your ,rd year< theyDre +ore likely to go easy on you( 7tDs okay to let your residents and preceptors kno# if you already have a specialty that

youDre hoping to go into( A co++on +yth is that people #ill ignore you or not call you tosee interesting things if you tell the+ you #ant to go into a specialty different fro+ theirs< 'ut< in general< people actually tend to 'e really supportive( $ften< they #ill try to give youpatients that are +ore related to #hat youDre interested in< so itDs co+pletely fine to 'ehonest< as long as you are respectful of the specialty youDre in( Also< if youDre interested infa+ily practice< no doctor has yet to criticie this career option< as everyone kno#s #e canal#ays use +ore G4s.

Study as you go( -ou canDt leave things until the fe# days 'efore the ea+ 'ecause thereDs#ay too +uch to cover.







Money andor a creditde'it card

-our phone

4ens

A granola 'ar

$ne eception to having your phone #ith you is in o'sgyn at BC *o+enDs hospital ? they donDt let youcarry one #ith you( And< of course< in every rotation< keep in +ind that itDs really unprofessional to 'e

checking face'ook #hile youDre supposed to 'e #orkinglearning(

Even #hen youDre in the $8 and #earing scru's< those things should fit in your pockets( The restof the ti+e< +ost students use and reco++end a s+aller +essenger?style 'ag that can 'e carried#ith you #ithout getting in the #ay too +uch( Backpacks are really cu+'erso+e< so lugging onearound #ith you is not reco++ended(

7f youDre at a site that provides a locker to you< 'y all +eans 'ring a 'ackpack #ith a lunch< a#ater 'ottle< study 'ooks etc( As you go through third year< youDll get a feel for #hat you needand youDll pro'a'ly find that you carry around fe#er and fe#er ite+s( *hat you need #ill also

vary 'y rotation< and there are so+e specifics in the rotation sections 'elo#(

%or call shifts< you #ill often have a locker< 'ut try not to 'ring anything irreplacea'le in case youleave your 'ag 'ehind( A fe# things you +ight #ant to 'ring #ith you for call shifts include"

tooth'rush 9 toothpaste

deodorant

hair'rush

s+all hand to#el

etra socksunder#ear @youDll pro'a'ly 'e #earing scru's< so you donDt have to #orrya'out other clothes

an etra s#eater or s+all 'lanket @the call roo+s can get 8EALL- cold< so itDs nice to haveso+ething etra that is coy((( you can also usually gra' etra hospital 'lankets fro+ near'yshelves if you needed

%$$!. And lots of it. @!onDt forget so+ething for 'reakfast.

study +aterials to read if things are Fuiet

)6 The CLE8SH74 GU7!E ; The Basics



H$* CALL *$8S

Generally speaking< your schedule for third year is Monday to %riday< 2 a+ to :?1 p+ @the startti+e +ay 'e earlier for rotations like surgery< and possi'ly a 'it later for others like psychiatry<and you +ay occasionally #ork later than 1p+ depending on #hat youDre doing and #here youare( Ho#ever< for so+e of the rotations @the 'ig ones< to 'e eact< you #ill also 'e on call( ThefreFuency of call varies 'y rotation and site< 'ut the concept is 'asically the sa+e(

$n the days youDre on call< if itDs a #eekday< you #ill #ork your usual day #ith your usualroundingnote #ritingpatient careetc( But< throughout the day< you +ay also 'e called to doconsults< #here you #ill get a history and do a physical ea+ on a patient that your service has 'een asked to see @usually in the e+ergency roo+< 'ut not necessarily( After#ards you #illrevie# the patient #ith either your resident or attending< and #ill co+e up #ith a plan together@e( ad+it to #ard< urgent surgery< outpatient follo#?up< etc( -our call shift #ill etend 'eyondyour usual end ti+e and you #ill continue to see consults throughout the evening and so+eti+esovernight( -ou +ay also 'e called for issues on the #ard( 7f things slo# do#n a 'it< you +ight 'ea'le to get so+e sleep( 7n the +orning< you #ill usually +eet up #ith your tea+attending and+ay round on patients or @if youDre lucky. get to >ust go ho+e( Most residents and attendings are

good a'out getting you out #hen youDre supposed to 'e finished call< 'ut 'e prepared to have toput in a little etra #ork if the need arises( %or call shifts on the #eekend< you +ay have a slightlydifferent start ti+e than during the #eek @although you #ill still start your shift so+eti+e in the+orning< and you #onDt necessarily do the sa+e daily activities you #ould nor+ally do on a#eekday( 7nstead< you +ay do a Fuick rounding on patients andor you +ay >ust 'e #aitingaround for consults or #ard issues( *hen it co+es right do#n to it< Jon callK is 'asically anotherna+e for Jreally long shiftK(

H$* $ BE A 4A8 $% -$U8 EAM

The easiest thing to do to 'e part of the tea+ is to 'e pleasant to #ork #ith( Be respectful andpolite< and sho# interest @even if you really hate the specialty youDre doing.( 7t #ill +ake a 'igdifference(

Aside fro+ enthusias+ and courtesy< get a sense for #hat needs to 'e done throughout the dayand start getting tasks done #ithout 'eing asked( So+e si+ple things that you +ight 'e a'le to doinclude printing out a patient list for everyone in the +orning< checking your patientsD charts 'efore rounds so you can ask a'out any issues that ca+e up overnight< and #riting ordersnotesin the patientDs chart during rounds to save ti+e later @although +ake sure you get a sense forho# things run 'efore doing this< 'ecause so+e residentsattendings +ay not #ant things #ritten

as youDre talking to the patient(


)) The CLE8SH74 GU7!E ; The Basics



Best clerkship s+artphone apps

Medscape @%ree ? A general disease reference that has Fuite a 'it of infor+ation for free

Upto!ate @%ree on your phone< 'ut reFuires a paid su'scription ? Handy if you already su'scri'eto Upto!ate(

BC Guidelines @%ree ? The app is si+ple< 'ut includes guidelines for co++on pro'le+s@dia'etes< asth+a< chest pain< etc( in BC(

!iagnosaurus @N)( ? Great for >ogging your +e+ory a'out the differential diagnosis for a#hole sle# of sy+pto+s(

id&or+ @N/( ? %ull of pediatric la' values< develop+ental +ilestones< and tons of other kid?related resources(

M! $n Call @N0( ? A Fuick reference to re+ind you of #hat to ask and #hat the differential is

for co++on pro'le+s youDll 'e called a'out #hen youDre on call

Medical A''reviations 'y O! 7deas @N6( P -ou +ay kno# that AMA usually +eans Jagainst+edical adviceK 'ut did you kno# it +eans so+ething totally different in o'stetrics @advanced+aternal ageI Avoid e+'arrassing +o+ents #ith this handy app on +edical a''reviations

Epocrates @%ree ? A good drug reference< and the 'asic version is free( The only do#nside is thatit doesnDt include Canadian drug na+es @an alternative #ith Canadian na+es is Tarascon?N,(

Calculate 'y OM! @%ree ? !o a #hole 'unch of co++on +edical calculations >ust 'y plugging

in the nu+'ers( @an alternative is MediFuations for N0(

La'! @N( ? Eplanations of various la' results( @An alternative is Medical La' Tests ? N/(

4E47! @%ree for 'asic version ? A toicology 9 antidote resource(

ECG Guide 'y OM! @N6( ? Has an ECG reference< sa+ples< and a Fui(

iMur+ur @N:( ? -ou can listen to real heart sounds to 'rush up on your auscultation skills(

&erve *hi @%ree ? A great reference for neurological pro'le+s ? you tell the app #here the

person is #eak or having sensory pro'le+s and it tells you #hat nerves are involved(

iBook!ropBoSky!rive etc for storing pdfs @Mostly %ree ? Having so+e #ay to store andvie# pdfs on your phone is very handy for studying on?the?go(

Mental &ote @N/( ? Great for taking notes or storing the +any call roo+ door codes.


)/ The CLE8SH74 GU7!E ; The Basics



Ho# to study during clerkship

8ead around your cases ? the infor+ation tends to stick 'etter and have +ore relevance.eep a note'ook #ith you so you can >ot do#n things to look up later(

The focus 'eco+es less on physiology and +ore on approaches and +anage+ent< so you+ay need to ad>ust your studying to acco++odate that change(

Make the +ost of your clinical ti+e 'y seeing as +uch as you can and asking lots ofFuestions(

Take advantage of acade+ic half days and teaching sessions< 'oth for+al and infor+al(Ask your residents Fuestions.

%ind a set of revie# 'ooks that you like @%irst Aid< Blueprints< &MS< etc and try to readthrough the #hole 'ook during your rotation(

To keep on track< creating a study schedule +ay 'e helpful( Make a list of o'>ectivesandor topics you need to cover and #ork out ho# +uch you have to readstudy each day<then do your 'est to keep to the schedule( Schedule in so+e 'reak ti+e< too< though.

*hat youDre studying during third year is the infor+ation youDre going to need on a day?to?day 'asis as a physician< so find a #ay to study that really helps you a'sor' the infor+ationand start to develop a #ay of approaching pro'le+s that is effective for you(


), The CLE8SH74 GU7!E ; The Basics



7s a car necessaryI

May'e( This is a difficult Fuestion to ans#er 'ecause it depends largely on #here you live< #hereyour rotations end up 'eing< and ho# +uch of a co++ute you are #illing to tolerate on the 'us

or a 'ike( Having a car certainly can +ake third year easier< 'ut if you donDt #ant the hassle orepense of o#ning a vehicle< students have +ade it through the #hole year #ithout one( 7f youlive in the 3GH area andor live near a B?Line 'us stop or Skytrain< youDll pro'a'ly 'e fine#ithout a car( Take advantage of the rotations #here you are given a choice of location andreFuest a near'y hospital as soon as you receive the e?+ail( eep in +ind< ho#ever< that +anyrotation locations are rando+ly assigned and you could 'e as far a#ay as 4eace Arch Hospital<#hich #ill 'e a challenge to get to #ithout a vehicle( =oining a vehicle co?op @e( ipCar is anoption for those #ho #ant occasional availa'ility of a car for convenience(





7+portant pearls of advice fro+

third year students

En>oy your ti+e no#. Be good to your fello# +ed students? share infor+ation and co++iserate(

-our eperience depends on ho# +uch effort you put into it(

Good luck( 7t #ill 'e a tough year(

Try to +ake sure you get as +uch sleep as you can( 7t is a +arathon year( 7t is challenging 'ut fun in the diversity that you get to eperience( 7f you donQt kno# so+ething on rounds<in the $8< etc(< look it up then or that night and it #ill 'e +ore likely to stick( Most peopleare +ore than #illing to help you if you are polite and respectful(

Make ti+e for the things you love( 7f youQre ʺtoo 'usyʺ to get to *histler for a day on thehill< get to the gy+< see your ʺlife friendsʺ< take a night off #ith your significant other or do#hatever else it is that +akes you happy this year< ho# on earth do you epect to fit that inonce youQre in residency or once youQre out in practiceI !onQt tell yourself youQll figure itout ʺlater ̋ 'ecause ʺlater ̋ isnQt going to 'e any less 'usy.

Try to rela and roll #ith the punches( -ou canQt possi'ly 'e prepared for everything< 'utyou can 'e interested and learn a lot fro+ asking Fuestions(

En>oy(

!onQt 'e a #hiner( The #orld has too +any of those( Love the clerkship( 7f you #ant to 'ea geriatric neurohe+atohepatopathologist you +ay hate o'stetrics< 'ut the 1 #eeks you getin o's #ill 'e the only dedicated ti+e you ever get to do it( So love it( *hen you are inpsychiatry< #ork and study like you #ant to 'e a psychiatrist< #hen you are in surgery< you#ant to 'e a surgeon( Catch +y driftI This #ill ensure you get the +ost out of eachrotation( This also prevents 'oredo+ or 'urnout 'ecause you let yourself 'e ecited eachday(

,rd year is a#eso+e( -ou get to do all the cool stuff you have 'een #anting to do.

Third year is +uch +ore fun than epected( !onQt #orry if you #erenQt the 'est student in

pre?clerkship( -ou can definitely catch up( !onQt assu+e you kno# anything ? 'asically< if you donQt kno# the ans#er< >ust say you

donQt kno#( &othing is #orse than trying to +ake up an ans#er that is clearly #rong( &otonly does it #aste ti+e< it also annoys the preceptor( 8e+e+'er< they asked you thatFuestion for a reason(

): The CLE8SH74 GU7!E ; The Basics



The first fe# +onths are over#hel+ingR itQs a nor+al feeling( -ou canQt 'ite off all of+edicine in days or #eeks( Learn a s+all a+ount @especially approaches to pro'le+s ratherthan the nitty gritty 'y reading around your cases and youQll accrue kno#ledge every day(

8ural is a+aing( Clerkship is #ay +ore fun and less stressful than everyone says it is< sorela and en>oy it(

Have fun and take care of yourself. Sleep 2 hours every night youQre not on call< and take atleast one full day off a #eek( eep yourself happy "

Be open to feeling foolish every day( Learning is +ore i+portant than 'eing right(

Hang in there(

Check your ego at the door( Assu+e nothing(

!onQt stress a'out order of rotations( 7t really does #ork out in the end(

Take things one day at a ti+e( 7f youQre ever feeling over#hel+ed< that is nor+al( Take adeep 'reath< and kno# this feeling is not forever( 7f you learn one thing fro+ each patientyou are in good shape(

Be on ti+e. @&o : +inute grace period. Be keen.

Have a fun?filled su++er after year /.

!onQt forget to en>oy life ? you kno#< that thing outside of +edicine(

-ou #ill 'e alright(





: things to take %ULL

advantage of .

)( %8EE %$$!.

There are lots of opportunities to snag free +eals or 'everages< such as during noon rounds<grand rounds< +orning rounds< other peopleDs rounds(((there is no sha+e #hen it co+es to thestarving +edical student( &or is there sha+e in going 'ack for seconds< or taking etra food to goafter the rounds are over( *ith a 'usy ,rd year< you never kno# #hen the net chance you +ightget to eat is(((

/( 8ES7!E& S.

They #ill 'e your greatest learning resource #hile at #ork or on call( Most are a+aing andeager to teach students< and you should definitely accept any offer for education they +ake( Even#hen #alking fro+ place to place< this poses a good opportunity to revie# the patient you >ustsa#< or co+e up #ith an approach for the net one co+ing up( Also definitely Fui the+ on theireperiences< satisfaction #ith their progra+< and any tips and tricks they +ight have for ea+s@they did >ust finish the+ not so long ago after all(((

,( &U8SES.

!o not underesti+ate the po#er of the nurse< and &E3E8 E3E8 get on a nurseDs 'ad side( They

can +ake your life Fuite difficult if they #ant to @luckily +ost donDt #ant to 'ecause theyDre sonice( =ust 'e collegial< treat the+ #ith respect< and ask #hat you donDt kno#( They have epertisethat even doctors donDt have @ie( they insert +ore 73s in a day than +ost doctors do in a +onth<and are often +ore than happy to let you do things for your learning @ie( inserting a foley or doingthat !8E. Also< talk to the patientDs nurse or read the nursing notes to get the full story of #hat#ent on overnight(

0( ACA!EM7C HAL%?!A-S A&! S4EC7AL -G8A&! 8$U&!S.

-ou never realie ho# a#eso+e lectures are and ho# +uch you +iss the+ until you get to thirdyear( These are opportunities #here you finally get a chance to sit do#n< not stress or rushevery#here< and actually learn #ithout having to think ecessively. 7tDs also one of the fe#chances you +ay have to reconnect #ith your fello# class+ates #ho you +ight not see +uch of<and actually get a chance to socialie and laugh #ith the+(




:( A&- S4A8E 7ME.

This co+es as a luury usually< 'ut can include ti+e you spend #alking to and fro+ yourcartransit stop to #ork< ti+e traveling across the hospital to another area< ti+e #hile #aiting torevie# a consult #ith a residentattending< or a lull in activities #hile on call( Use this ti+e toread your revie# 'ook< to learn fro+ your s+artphone< to eat anything you can get your handson< to take a Fuick afternoon nap< or to hedge so+e sleep ti+e early on in the call shift in case allhell 'reaks loose at /a+.





en +o+ents that #ill happen in

,rd year

*ritten 'y Andy Chen< M! /6),

Although everyoneDs eperiences in ,rd year #ill 'e their o#n and uniFue to everyone elseDs<there are certain co++onalities that every student #ill likely eperience at so+e point duringtheir rotations< 'e it during the intense 'ig ,< or in one of the s+aller rotations( At so+e point<these +o+ents #ill occur< and hopefully this section #ill so+e#hat prepare you for it #hen theydo( *hen encountered< it isnDt the end of the #orld< and there are al#ays #ays to adapt to sucho'stacles(((even if so+eti+es it doesnDt actually look that #ay(

At so+e point(((

)( -$U *7LL %EEL S U47!(

This is inevita'le( &o +atter ho# +uch you think you learned in your first / years of +edicalschool< and ho# +any 4BL patients youDve diagnosed and saved< there #ill co+e a so'ering+o+ent #hen you realie< J(((crap 7D+ an idiot(K This isnDt to say that #e arenDt good students ors+art people< itDs si+ply a +atter of fact that #eDre still 'udding doctors in training< #ho lack theeperience and eposure necessary to understand the co+pleity of the hu+an 'ody and all itsdiseases(

This event freFuently happens during grilling sessions #ith attending< #here not only is recalling

the facts hard enough< itDs +ade harder 'y the pressure of 'eing in the hot seat( Avoid u++s andahhs and truly take )6 seconds to sort through your thought processes to find an ans#er( 7f youdonDt kno# after ): seconds< you pro'a'ly donDt kno# at all< or #onDt recall it #ithout so+e kindof hint( =ust ad+it you JcanDt recall right no#K @#hich sounds 'etter than J7 donDt kno#K< andsay youDre taking a 'est guess @try to >ustify #hy youDre guessing this #ay( Also cross yourfingers that your doctor doesnDt love a good ga+e of Jguess #hat 7D+ thinkingK< #hich is nighi+possi'le to #in at< so donDt feel too 'ad a'out it(

Take this in stride< >ot do#n #hat it is that +ade you feel stupid< and +ake it a point to go ho+eand read up on it( -es< the net ti+e it co+es up youDll forget : of #hat you read a'out andagain feel like a co+plete du+'ass< 'ut youDll once again go 'ack and reread the topic< retain alittle +ore< and 'it 'y 'it #e learn to 'eco+e actual doctors( Until then< one can only hope thatour stupid +o+ents donDt co+e in front of an audience< 'e they attending doctor< class+ate< orpatient(((

) The CLE8SH74 GU7!E ; The Basics



/( -$U *7LL BE S$ %A 7GUE! A&! !8A7& E! -$U CA&D

%U&C 7$&(

7f you thought your years of pulling all?nighters to finish ter+ papers and cra+ study for ea+shas prepared you #ell for the long hours of #ork for over half of the year< you underesti+ate thepo#er of the on?call shift( The specialties of internal +edicine< surgery< pediatrics and o'sgyn allvie for the title of 'eing the Sleep !eprivation Cha+pionD< +eaning on average< any night #hereyou can get , hours of uninterrupted sleep counts as a 'lessing( ThereDs nothing like trying to

take a patient history #hile youDre fighting >ust to try and stay a#ake< and at ti+es closing youreyes #hile listening to heart sounds isnDt 'ecause youDre trying to focus(

This +eans that any sleep< any#here< should 'e sought( This includes on the 'usskytrainco++ute< the +a>ority of post?call days @#hat else are they for< and yes< even during acade+ichalf?days @assu+ing youDre not at the host site< itDd 'e a little rude to snore in front of thelecturer( *hen you are on call< ai+ for your 'edti+e to 'e as soon as thereDs a lull in activity@#hich +ay 'e the cal+ 'efore the stor+< as itDs a co+plete roll of the dice regarding #hat kindof night you +ight have(

So+e residents and students do a set of Jtuck?inK rounds< in #hich they go to the #ard and checkin #ith the nurses a'out any concerns #ith any of the patients( 7deally you can avoid having anurse call you in the +iddle of the night a'out a patient una'le to sleep 'ecause so+eone didnDt#rite a opiclone order on ad+ission( 7t also gives you a heads?up early a'out any potentialpro'le+s that +ay arise< so if you do get called later< you have an idea a'out the patient andissue< rather than trying to figure things out as you #ipe the sleepiness fro+ your eyes(

,( -$U *7LL C$&S7!E8 A&$ HE8 S4EC7AL - !7%%E8E& %8$M

-$U8 $87G7&AL 4LA&(

Many of us go into ,rd year @or even )st year dead set on our future career( Everyone kno#s aperson in class #ho s#ears 'y general surgery< der+atology< plastics< etc( *hatever yourco++it+ent level is to your specialty of choice< at so+e point in the year you #ill 'egin to dou'tyourself( 4erhaps itDs during the rotation of said specialty< #here you realie you donDt like1",6a+ rounding follo#ed 'y full $8clinic days and patient rounds until 5p+( $r it could 'eafter having co+pleted another rotation you thought youDd hate or not care a'out< >ust to realiethe specialtyDs actually Fuite a+aing and decide youDve 'een too hasty to >udge it(

8egardless of #hen your identity crisis occurs< in the +a>ority of circu+stances it isnDt too late tochange your plans( 0th year elective selection doesnDt 'egin until early March< so you can al#ays#affle on your career plans until then( Even after#ards< thereDs opportunity to change yourelectives @difficult< 'ut not i+possi'le< and in so+e cases< students even take /nd clinical 'lockelectives @post?Ca8Ms application deadline in their ne# specialty of interest so they can >ustifytheir applications to those residency positions should they 'e offered an intervie# 'y progra+sthey applied to( =ust 'ecause you love a specialty on paper doesnDt +ean youDre co++itted to itfor good< especially not until after youDve eperienced it first?hand(

/6 The CLE8SH74 GU7!E ; The Basics



0( -$U *7LL MESS U4 $8 %$8GE $ !$ S$ME H7&G 8ELA E!

$ 4A 7E& CA8E(

7tDs often difficult enough to track everything there is to kno# and do for >ust one patient< letalone the 0 patients youDre follo#ing( A+ongst all the orders< investigations< and consults to 'edone< thereDll unfortunately 'e one or +ore instances #here you forget to do so+ething or +ake a+istake in your orders( The severity of this can vary< as can the adverse outco+es< and althoughhopefully 'oth are +ini+al< the +ost i+portant thing is to correct your error(

7f youDve realied it early enough to correct it #ithout any pro'le+s @e( #rote the #rong+edication order< 'ut it hasnDt 'een processed< then si+ply go 'ack to change it or add an orderyou forgot( 7f the orderDs 'een processed< 'ut only recently< you can al#ays #rite thecancelchanged order< 'ut +ake sure you let the nurse kno# directly as #ell to +ake sure theoriginal directions isnDt perfor+ed(

7n the cases though #here youDve realied or recalled the issue too late to correct< or youDre asked 'y your resident or attending regarding the pro'le+< the +ost i+portant thing is to o#n up to it(

Ad+it that you +ade a +istake< and either youDre asking for instructions a'out ho# to rectify the

pro'le+< or that youDve already +ade the first steps to#ards fiing it( Although you +ay getso+e flak for it< itDs far 'etter to 'e honest #hen caught< then to 'e caught later on after youDvelied( Most supervising doctors are forgiving and realie that #eDre students #ho are still learningthe ropes( =ust 'e sure not to +ake the sa+e +istake t#ice. 7n the end< the +ost i+portant thingis patient safety and care< #ith any action or +istake #e +ake having a direct i+pact on their#ell?'eing< and thus our pride and fears of getting a 'ad evaluation should co+e second to ourresponsi'ilities as care providers(

:( -$U *7LL E&C$U& E8 =E8S A&! BULL7ES(

They +ay 'e attendings< residents< nurses< unit clerks< patients< or so+eti+es even class+ates< 'utat so+e point so+eone #ill 'e rude< +ean< >udg+ental< inappropriate< or all of the a'ove toyou( 7n all hopes< these people #ill 'e far and fe# 'et#een the +any other encounters #ith verygenuine and nice people( Should you encounter a >erk or 'ully< ho#ever< you +ay find yourself ina difficult position of #hich it see+s the only #ay out is(((no#here in sight(

*hat you can do ho#ever< is approach the pro'le+ #ith a cal+ +ind and evaluate< in order"yourself< the situation< then the person youDre dealing #ith( %irst look at yourself and ask if you+ade so+e error or +istake that #arrants the response youDve received( 4erhaps youDre having a 'ad day too and your attitude and interactions are a little less friendly than usual< and as a resultothers are reciprocating #hat they hear fro+ you( 7f thatDs #ithout issue< +ove on to looking atthe situation( 7s it currently a high?stress environ+ent such as a critical ti+e in the +iddle of anoperation or an overly 'usy clinic dayI 7s this out of keeping #ith the J>erk'ullyDsK usual 'ehaviour on other days to#ards you< #hich +ay point +ore to#ards the+ having a 'ad day asopposed to their nor+al friendly self( Lastly if all of the a'ove isnDt true< then youDre likely >ustdealing #ith a straight?up (

/) The CLE8SH74 GU7!E ; The Basics



!onDt panic< as so+eti+es these people prey on fear and aniety and si+ply press on to +akethings #orse( 7nstead< stay cal+< act #ith logic and reason< and accept the fact youDre in anunfortunate position that youDll have to 'ear through until the end of it( Si+ply co+plete yourduties to the 'est of your a'ilities< respond in a #ay that generates as little a conflict as possi'le<and re+e+'er to take +ental notes for #hen you fill in $ne0: evaluations later( Ho#ever< if itever reaches a point #here you feel attacked< unsafe< or o'serve actions that put patients at risk<speak up( Contact either the site rotation director< or get in touch #ith the $ffice of StudentAffairs( Both options #ill provide guidance and support as to #hat you can do< and can also look

further into the issue #ith confidentiality(

1( -$U *7LL C8- @$8 *A& $(

This could 'e for a variety of reasons( 4erhaps youDve had a rough day< are ready to drop dead#ith fatigue< and still have , +ore patients to round on in the afternoon( May'e you >ust gotpi+ped 'y your attending and co+pletely 'lanked on all the Fuestions< +aking a total fool ofyourself( $r< unfortunately< there are ti+es you encounter a patient situation that 'rings forthsuch sadness in you that tears need to 'e held 'ack< such as #hen a patient is dying< or oftenduring the pediatrics rotation #ith very ill children(

8egardless of the occasion< itDs i+portant to realie thereDs a ti+e and a place for everything< andopenly crying in the +o+ent generally isnDt the 'est idea( !o your 'est to hold the tears 'ack<take a deep 'reath< and focus on the tasks that need to 'e done in the present( ThereDs alsonothing #rong #ith ecusing yourself for a +o+ent to gather yourself and Fuickly dry any tearsthat +ight 'e co+ing forth< 'efore going 'ack to the #ork at hand(

7f itDs 'een a rough day< +ake sure you take so+e ti+e #hen you get ho+e to eat< rela in#hatever #ay you prefer< and let out any e+otions you have( Call up so+eone to talk to< such asfa+ily< a friend< or a class+ate< to vent< rather than pent @it all up( 7f you felt stupid not kno#ing

ans#ers asked 'y your attending< re+ind yourself that youDre only hu+an and no one kno#severything right off the 'at( 7nstead< think of #hat tripped you up< read #hat you donDt kno#<and revie# #hat you already do< so that the net ti+e youDre ready to rattle off those facts#ithout hesitation( And if your tear #orthy +o+ent involves a patientDs condition< so+eti+esitDs ok to share a +o+ent to cry #ith the patient andor their fa+ily if youDre co+forta'le doingso and feel that theyDve gotten fa+iliar #ith you enough to accept your display of e+otions( 7fnot< #ait until you have the chance to reflect on your feelings and can find so+ething thatco+forts you #hen youDre do#n @a pet is great for this< or can cheer you up @a pet is also greatfor this(

// The CLE8SH74 GU7!E ; The Basics



5( -$U *7LL MEE S$ME$&E A 8AC 73E *H7LE *$87&G(

LetDs face it< all of us in the health professions are a good looking 'unch( At so+e point or other<youDll +eet a doctor< resident< nurse< unit clerk that you canDt help 'ut find attractive( 8egardlessof #hat their relationship status is< #hat signals you think they +ay 'e sending< or #hat flirting+ay 'e going on< al#ays keep in +ind the i+portance of professionalis+ and ethics( -our careerand credi'ility is certainly not #orth risking 'y +aking the #rong +ove< no +atter ho# 'adlyyou #ant to ask that other person out( As long as youDre still #orking directly #ith the person<

you shouldnDt +ake things a#k#ard or inappropriate 'y +aking advances( And yes< although ifitDs the last day youDll 'e #orking #ith so+eone and arenDt likely to get another chance to see or#ork #ith the+ again in the future< therefore it feels like a good chance to test the #aters< do stillkeep in +ind that #ord does get around< and gossip spreads like #ildfire in the hospital setting(So if you scre# it up< it +ight not >ust 'e 'et#een the t#o of you(

2( -$U *7LL BE 8744E! U4 B- A 4A 7E& (

This occurs #hen you take a great history fro+ the patient in #hich you asked all the rightFuestions< then su++arie to your attending in a perfectly paced and succinct +anner( Then

#hen the attending co+es #ith you to see the patient< and they ask so+e Fuestions< the patientgives co+pletely different ans#ers to #hat they told you< or 'rings up so+ething that they deniedearlier on(

J$h +edications< yes< 7 take so+ething called #arfarin(K ? patient @.N9V 'ut 7 asked youthat )6 +inutes ago and you said you take no +eds. ? you think to yourself< as you sheepishlylook at your attending(((

7 call it 'eing trolled 'y a patient< and then in +y i+agination 7 feel like theyDll turn to look at +eas if to say Joops< sorry< u +adIK 7tDs even +ore frustrating if it happens +ore than once #ith the

sa+e patient< or #ith +ore than one patient in a day( &ot only do you feel e+'arrassed 'ecauseyou look like a fool for +issing key pieces of infor+ation< 'ut you lose credi'ility #ith your staffif it happens repeatedly(

7tDs 'est to not get too frustrated #hen this happens< and to keep in +ind so+eti+es patientsgenuinely do forget to +ention i+portant things< or donDt +ention it 'ecause to the+ itDs no# thenor+ or they donDt find it an issue( Many a patient say no #hen you ask Jdo you have high 'loodpressureIK 'ecause they !7! 'ut no# are on anti?hypertensives and have a &$8MAL 'loodpressure(

7nstead< take things in stride< and if your attending asks you later on #hy you failed to +ention

so+ething< politely eplain that you did ask 'ut the patient gave you a different ans#er( &ever >u+p the gun though and confront< or #orse< argue #ith the patient on the spot a'out the issue<as itDll >ust +ake you look even #orse( Hopefully +ost doctors #ill 'e forgiving and understandthese things happen< and >ust +ove on(

/, The CLE8SH74 GU7!E ; The Basics



-ou can try to pre?e+ptively guard against this situation fro+ arising 'y asking patients Fuestionsin a specific #ay< such as providing a +ultitude of ea+ples to >og their +e+ory( 8ather thanJdo you have any +edical conditionsIK< try Jdo you have any +edical conditions< such as high 'lood pressure< high cholesterol< dia'etes< lung< liver or kidney disease< or a past history of heartattacks< stroke< 'lood clots< or cancersIK 7tDs a +outhful< 'ut if you get in the ha'it of asking it inthis #ay you can save yourself Fuite a fe# pitfalls hopefully( The sa+e goes for #hen youDrepresenting to an attending or resident( State that Jthe patient denies having hypertension< lungdisease< dia'etes< past histories of(((K @tailor it so you list ,?0 of the key negatives< then end #ith

Jor any other +edical conditions( At least this #ay if it still happens #here the patient goes Johyeah< 7 did have cancer years agoK and you feel like 'anging your head against a #all or cra#lingunder the patient 'ed< you kno# youDve already done everything you could to safeguard againstthis event(

( -$U *7LL *A& $ G73E U4(

7t +ay co+e #ithin the first +onth of clerkship< or you could hold out until the end of the year(Typically it happens so+e ti+e during the 'ig ,< pro'a'ly after a 'rutal call shift( -ouDll

Fuestion #hy youDre even here< #hy you even 'other< and #hy everything see+s so hard or if

youDre >ust not cut out for this( Then you #onder perhaps itDs 'etter if you Fuit 'efore youactually fail< and then one thing leads to another and 'efore you kno# it youDve #orked yourselfinto a freny of aniety and fear a'out the possi'ility of flunking +ed school< and >ust #annagive up and 'eco+e a lo#?level e+ployee in a fastfoodrestaurantoraclothing storeinsteadGAS4.

Stop( Breathe( 8e+e+'er #hat got you here so far( 7f they +ade a +istake and let you into +edschool 'y accident< they #ouldDve figured that out 'y no#< and if youDre as du+' as you feel youare< you #ouldDve flunked out already( &either of those facts are true< so that +eans you deserveto 'e #here you are and youDll +ost certainly +ake it through( $rganie your schedule to sort

out your #ork< study< and personal ti+e< +ake it a goal to learn , ne# facts a day at the veryleast< and rely on your fa+ily and social supports for so+e reassurance< encourage+ent< andrelaation( 4ut the thought of giving up out of your +ind< since that option isnQt even on theta'le 'ecause it doesnDt need to 'e( Everyone #ill +ake it through(

)6( -$U *7LL %EEL 48$U! $% -$U8SEL% A&! -$U8 *$8(

7n 'et#een all the a'ove +o+ents of pressure< frustration< aniety< fear< and confusion< there #illco+e a ti+e #hen you do so+ething right( So+ething that +akes you feel s+art< pleasantlysurprised< proud< and start to +ake you realie that perhaps you are cut out for this< and thatyouDre on the #ay to 'eco+ing a good doctor( Then that +o+ent #ill happen again< and again<and continue on #ith increasing freFuency throughout the year( Congratulations< youDre learningto 'e a doctor(

/0 The CLE8SH74 GU7!E ; The Basics



7tDs all too easy to forget that those a+aing genius doctors and residents #e look up to have atthe very least< / etra years @if not /6 of eperience and learning on us( They +ost certainlydidnDt kno# everything they do no# #hen they #ere at our stage< and even despite so+e of theirepectations @#hich can 'e unrealistic< #e canDt kno# everything they kno# no#( MedicineDs a+ulti?step process< and the learning curve #ill 'e revisited over and over again< 'ut #ith eachrepetition< the curve #ill 'e less steep and shorter in length(

*hen you actually end up doing so+ething right or kno#ing the ans#er to so+ething hard< feel

proud( 8e+e+'er these +o+ents< and co+e 'ack to the+ #hen youDre feeling inadeFuate andFuestioning yourself( !onDt forget that even if so+eti+es your effort feels unrecognied orunappreciated< you have +ade so+e kind of difference in the lives of your patients< and that thisis #hat your future #ill hold( *e +ight not 'e doctors Fuite yet< 'ut #eDre certainly on our #aythere #ith each of these +o+ents(


/: The CLE8SH74 GU7!E ; The Basics



!$CUME& A 7$&


Edited 'y La#rence Haiducu< M! /6)0

Ho# to #rite consults< orders< notes and dictations(((((((((((((((/5

7( Startend of anything #ritten and general tips((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (/2

77( Consultations and dictations((( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( /

777( Ad+ission orders((( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ,1

73( !aily progress notes and orders((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (,

3( !ischarge dictations and su++aries((((((((((((((((((((((((((((((((06

37( 4rocedure notes and orders((( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 0/

377( Specialty specific aspectsco+ponents((( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( (0,

/1 The CLE8SH74 GU7!E ; !ocu+entation



Ho# to #rite consults< orders<

notes and dictations



!ocu+entation is a crucial aspect of +edicine and< as +edical students< it is our responsi'ility tolearn ho# to #rite appropriate consultations< orders< and notes( &ot only is it a co++unicationtool to relate infor+ation to other healthcare staff involved #ith the care of the patient in thepresent and future< 'ut it also plays a potential role in legal issues< and thus should 'e takenseriously(

!ocu+entation should 'e succinct< relevant< and of course< legi'le. !octors have 'een plagued#ith a type of acFuired dysgraphia that presents at varia'le periods later on in our careers< 'ut the

+ost effective prophylais is developing good #riting ha'its early on( This +eans #riting on thelines< picking up your pen off the page in 'et#een every #ord at the very least @if not 'et#eenevery letter< avoiding o'scure a''reviationsacrony+s< and re#riting anything you think +ightnot 'e reada'le( &ot only #ill colleagues appreciate you for this< 'ut itDs in the na+e of patientsafety( Although not all of us #ere 'lessed #ith advanced calligraphy skills< even the #orst of uscan +ake our chicken?scratch lettering legi'le #ith +ini+al effort(

Lastly< every specialty has a particular style and preference for their docu+entation< as #ell aspossi'ly containing uniFue focuses or co+ponents( 7nternal +edicine progress notes reFuires a#ell detailed differential diagnosis and +anage+ent plan< surgeryDs focus is on co++on post?op

co+plications @e( fever< and pediatrics al#ays #ant to kno# fluids inouts and #eight changes(Beco+e fa+iliar #ith 'oth #hat the specialty looks for< and #hat your attending and residentsprefer< and tailor your #riting to those epectations initially< until #ith ti+e< you 'eco+eco+forta'le having developed your o#n +ethodology and style.





7( Startend of anything #ritten

and general tips

8egardless of #hat youDre #riting< it should al#ays have so+e co++on co+ponents"

)( Every consult< note or order should identify so+e#here near the top or at the start< #hatservice is involved @e( internal +edicine< #ho is #riting @e( MS7 ,< and #hat is 'eing #ritten@e( progress note( 7t also helps to underline this< #hich helps for Fuick reference as to #hat thenote is< and to 'e a'le to find previous notes easier($ther ea+ples" JSurgery MS7, ? 4$! V) progress noteK @4$!Wpost?operative day<J4ediatrics MS7, on call ? overnight noteK< J7nternal +edicine MS7, ? addendu+ noteK(

/( The date and ti+e of #riting should 'e on the top left side of the note or at the top of the

consult( *rite this out as J+onth day< yearK @ie( Apr )st< /6)/< in order to avoid confusion( Theti+e of #riting should also 'e docu+ented in /0hr ti+e @e( )166h< not 0"66< #hich +ay reFuirepractice 'efore it 'eco+es intuitive( This is again to avoid potential confusion #ith AM4M @orforgetting to #rite the+(

7f you stop your note half#ay to do so+ething else< then co+e 'ack to it a #hile later< you shouldupdate the ti+e of the /nd half to avoid confusion regarding ti+ing @e( having la' results on aJ+orningK note fro+ orders you #rote in the afternoon( Alternatively< you can start a ne# notetitled Jaddendu+(K

,( Anything you #rite should 'e co+pleted #ith your signature< your na+e printed< level oftraining @e( MS7,< your pager nu+'er< and if it #as discussedrevie#ed #ith an attending orresident @reFuired for +ost physician orders( %or ea+ple< a note +ay 'e ended #ith a signatureand JAndy Chen< MS7,< 160(0:6(/,2:< d# !r( HouseK( 7f it #as revie#ed #ith a resident<identify their year of training @e( J8,K after their na+e(

0( 7f you ever +ake a +istake in #riting< cross it out #ith a single horiontal line< then #riteJerrorK and initial 'eside or a'ove it to verify that a +istake #as +ade( Continue on #riting netto the error( 7f you ever need to insert etra #ords or phrases retrospectively< initial those too(

:( 8efer to yourself as J#riterK @e( JpatientDs nurse told #riterK( 7f you use na+es for other

people< put their position in 'rackets @e( J#riter discussed #ith =ane @8&K(

1( Avoid +aking up a''reviations or using unco++on ones( 7f in dou't< #rite it out.

5( *hen #riting orders< only ) order per line. %or ea+ple< each +edication 'eing orderedshould 'e on its o#n line< not chained together in a continuous sentence(





77( Consultations and dictations

Most patient cases 'egin #ith a consultation in e+ergency< regardless of #hat service youDre on(As usually youDll 'e the first +edical personnel to have ti+e for a full assess+ent of a patient and

their pro'le+s< a co+plete history should 'e taken( Each rotationspecialty #ill have apreference for #hat to focus on< as #ell as uniFue parts to a co+plete history< 'ut all of the+should have the follo#ing co++on ele+ents"

4atient identification and reason for referralchief co+plaint

History of presenting illness

4ast +edicalsurgical history and revie# of syste+s

Medications

Allergies

Social history

%a+ily history

4hysical Ea+ination

7nvestigations and la'#ork

7+pression

!ifferential diagnosis

4lan

)( 4A 7E& 7!E& 7%7CA 7$& A&! 8EAS$& %$8 8E%E88ALCH7E%

C$M4LA7& "

This should 'e a sentence stating #ho the patient is< relevant +edical conditions< and #hy they#ere referred to the service or #hy they ca+e in to the hospital(E( JMr( Ed 7ssine is a :0 year old Caucasian +ale #ith a : year history of hypertension andrecently diagnosed dia'etes type / presenting to E! #ith co+plaints of chest pain that started anhour ago lasting for )6 +inutes< #hich #as relieved #ith rest(K

/ The CLE8SH74 GU7!E ; !ocu+entation



/( H7S $8- $% 48ESE& 7&G 7LL&ESS"

This section details the events leading up to their current condition< including any pre?eistingassociated +edical conditions( Although initially the ti+efra+e is dictated 'y the patient @e(they state their pro'le+ started that +orning #hen they felt a dull pain in their chest< the priorhistory should 'e eplored to elicit any other relevant details @e( theyDve actually had high 'loodpressure for the last : years( 7t should also include the events that have occurred since they #ere 'rought to hospital @e( the E! physician has seen the patient< ad+inistered nitroglycerin )

spray< and ordered CBCelectrolytestroponin( %or taking the history< one can use theLM&$4O8STU3 structure @or any other +ne+onic preferred"

Location" *here is the pain or co+plaintI May not 'e one specificlocalied area(M

anage+ent+edications" *hatDs 'een done a'out itI *hatDs 'een takenI&e#old" 7s this the first ti+e this has occurred< or is it a chronic pro'le+I$

nset" *hen did it startI 7s it still ongoingI4recipitatingrelieving factors" *hat +akes it 'etterI *hat +akes it #orseIO

uality" *hatDs the pain likeI 7s it sharp< dull< thro''ing< aching< 'urning< etcI8

adiating" !oes the pain spread any#here elseI !o you have shooting painsI

Severity" Ho# 'ad is the pain on a scale of ) to )6 @)Wno pain< )6WecruciatingI

i+ing" !oes it co+e and go< or is it constantI 7s it 'etter#orse at a certain ti+e of dayIUnusual features" 7s there anything else odd or uneplained that youDve noticedI3

arious conditions" Are there any +edical conditions you have that are relatedI

,( 4AS ME!7CALSU8G7CAL H7S $8- A&! 8E37E* $% S-S EMS

7nFuire a'out any other +edical conditions the patient has< #hen they #ere first diagnosed<#hatDs 'een'eing done a'out the+ @e( +eds< doctor follo#ing this< and if itDs causing the+any pro'le+s right no#( Surgeries should have a date of occurrence< a hospital location< the

reason #hy< and if there #ere any co+plications during or after#ards( A 'rief revie# of syste+sshould 'e perfor+ed here to elicit any other +edical conditions the patient +ay have forgotten orare undiagnosed( %reFuently patients +ay say Jno 7D+ pretty healthy<K until you ask the+ if theyhave high 'lood pressure< dia'etes< or high cholesterol< #hich >ogs their +e+ory and they stateJoh yeah< that(K *rite do#n negatives to indicate you did actually inFuire a'out the+ @e( Jnosy+pto+ history of C$4!< CH%< G7 issues< infections<K etc(((

0( ME!7CA 7$&S

A co+plete list of +edications the patient is currently taking should 'e co+piled< including thedosages< route< and freFuency( %urther infor+ation should 'e gathered regarding ho# longtheyDve 'een on the +edication< #hat itDs for< if itDs 'een effective for the+< and if there have 'eenany side effects or adverse reactions( Many patients +ay not re+e+'er the na+es of their+edications< 'ut kno# itDs for the heart< or for asth+a< and thus +ay reFuire so+e +e+ory >ogging fro+ the student(

,6 The CLE8SH74 GU7!E ; !ocu+entation



$ne can also refer to the 4har+anet report for the patientDs recently filled prescriptions< 'ut donDtrely on this co+pletely as so+e +edications patients +ay fill 'ut not take< and so+e +edicationspatients +ay take 'ut arenDt on 4har+anet @e( G4 office sa+ples( 7tDs 'est to go through the list#ith the patient and ask if theyDre still taking each +edication( 7f they stopped taking anyparticular +edication< ask #hy(

Also< donDt forget to inFuire a'out naturopathicher'al +edications< over?the?counters< and illicit+edications @ask specifically J+ari>uana< cocaine< heroin< crack< or other illegal drugsK< as not all

patients consider certain +edications JillicitK(

:( ALLE8G7ES

7nFuire regarding any food< drug< or other allergies< and if there are any< ask specifically ho# theykno# theyDre allergic to this< and #hat eactly happens #hen the patient is eposed to this( Thisneeds to 'e differentiated 'ecause often patients 'eco+e +ied up 'et#een a true allergicreaction @e( anaphylais< rash< a fooddrug intolerance @e( nausea< diarrhea< and #hatDssi+ply a drug side effect @e( dro#siness< +alaise( Also ask #hat resolves the allergy< and ho#long it usually takes(

1( S$C7AL H7S $8-

This section is concerned #ith the patientDs personal 'ackground< living situation< availa'lesupports< and other social factors that +ay play a role in their health( eep in +ind that the ti+eavaila'le for the histories is li+ited< and often +uch of social history #ill need to 'e postponeduntil after ad+ission( $nly ask #hat you think could 'e relevant< 'ut also feel free to use +anyof these Fuestions as rapport 'uilding tools to get to kno# your patient 'etter and sho# youDreinterested in #ho they are< not >ust #hat +edical condition they +ight have. 4ersonal 'ackground infor+ation can include"

Ouestion 8elevance

*here #ere they 'orn and #here

did they gro# upI

Cultural 'ackground and child develop+ental situationcan play a role in their 'eliefs on health and actualhealth

*hat their religioncultural 'eliefs

areI

May affect their decisions for accepta'le +edicaltreat+ent @e( =ehovahDs #itness< no 'lood transfusions

*hat level of education did they

achieveI

Affects their general social functioning< a'ility tounderstand your use of +edical language and care plan

*hat >o' do they currently have or

had heldI

$ccupational haards @e( lead eposure +ay 'e

relevant< and also provides info regarding currentfinancial situation

*hat ho''ies do they haveI $ther eposuresrisks @e( pigeon?keeping< +ushroo+far+ing

*hatDs their current +arital

statusI Any childrenI

Spousespartners and children can provide collateralinfor+ation< or +ay 'e a source of stress or har+ @ie(a'use

,) The CLE8SH74 GU7!E ; !ocu+entation



Their living situation relates to #here they live< #hat kind of place they live in @e( house< condo<do they o#n or rent< #ho lives #ith the+< do they feel safe at ho+eI

Availa'le supports can include fa+ily< friends< +entors< educators< or advocates( !o they feel likethereDs so+eone #ho can help the+ in ti+es of need or ill healthI

$ther social factors include stressors< dangers or risks to their health< financial strain< recentsignificant life events or trau+a< and any other #orries or concerns(

Specific inFuiry +ust 'e +ade into their s+oking and drinking ha'its( 7f they say they donDts+oke< do they +ean no#< or ever in their lifeI 7f they say they dodid s+oke< ho# +uchI Ho#longI Ho# freFuentlyI Have they plannedatte+pted to Fuit 'eforeI Ho# do they feel it affectstheir healthI

7n regards to alcohol use< ho# +any drinks per night#eekI *hat happens after theyDve drunkIHo# do they feel a'out their drinkingI Have there 'een any adverse effects @e(cirrhosis< socialdysfunction< etc( 7f necessary< a CAGE screen @cut do#n< annoyed others< guilty a'out< eye?opener use can 'e used< ti+e per+itting on an appropriate candidate #here alcohol a'use +ay

'e suspected(

7n either the case of s+oking or drinking< one should initially grossly overesti+ate the a+ountthat so+eone +ay s+okedrink( 7f the student suggests Js+oking ,?0 packs a dayK or Jhaving)6?): alcoholic drinks a nightK< it encourages the patient to ad+it to their actual a+ount< #hichis usually less than this etre+e 'y co+parison< in the patientDs +ind< and additionally assessestheir idea of Jnor+alK a+ounts @e( one patient encountered considered an entire 'ottle of#hisky as 'eing Jnot that +uchK.(

5( %AM7 L- H7S $8-

A fa+ily pedigree should 'e dra#n to de+onstrate first degree relatives #ith their correspondingages( Any history of the presenting condition a+ong other fa+ily +e+'ers should 'e eplored<including if they #ere for+ally diagnosed< ho# they #ere +anaged and #hat thecurrentplanned treat+ent is for those individualsI Are there any other inherita'le conditions@e( HuntingtonDs or illnesses that have a fa+ilial co+ponent @e( dia'etes<hypercholesterole+iaI

7t is not sufficient to ask Jis there any fa+ily history of illnessesIK as +any patients #onDt havegood spontaneous recall of fa+ily conditions( 7nstead< +ake suggestions of co++on illnessessuch as high 'lood pressure or cholesterol< dia'etes< heart or lung disease< cancers< liver or kidney

pro'le+s< +a>or surgeries< and any co++on types of disease related to the patientDs likelydiagnosis(

,/ The CLE8SH74 GU7!E ; !ocu+entation



7f any positives turn up< ask regarding ho# old #ere they #hen they #ere diagnosed< #hat agethey are no# or at #hat age did they pass a#ay< #hat kind of treat+ent+anage+ent #as done<ho# effective this #as< and #hat their current status is( This +ay 'e ti+e consu+ing if oneDsco++on sense is not used to decide #hat is or isnDt relevant to the patientDs current situation @ie(donDt need to eplore an uncleDs history of ece+a if the patientDs current co+plaint is pain #ithurination(

2( 4H-S7CAL EAM7&A 7$&

A focused physical ea+ should 'e perfor+ed on the organ syste+ suspected to 'e the leadingdiagnosis< and screening ea+s should 'e perfor+ed on the other syste+s( Every patient caseshould have vitals takennoted @see figure 'elo# for shorthand for+< and depending on thelength of ti+e elapsed< +ay have 'oth the vitals on triage and vitals no# >otted do#n @as anychange can 'e relevant(

The +a>or syste+s to ea+ine and the 'asic Fuestions are listed 'elo#"

Head and neck @HX&" 4upils eFual and reactive to light and acco++odates @4E8LAI

Etraocular +ove+ents intact @E$M7I Ty+panic +e+'ranes and oropharyn nor+alI&eck suppleI &o ly+phadenopathyI Thyroid nor+alI

Cardiovascular @C3S" 4ulse rate< a+plitude and rhyth+ nor+al in 0 li+'sI =34 nor+alheight and characteristicsI Heart sounds nor+al in 0 areasI Any +ur+urs< thrills< heaves<or arrhyth+iasI Any peripheral ede+aI

8espiratory @8ES4" Breathing rate nor+al and regularI Good 'ilateral air entry@GBLAEI Any crackles< ru's< or #heeesI Any pain or dullness on palpationpercussionIAny a'nor+al ri' cage or diaphrag+atic +ove+entsI

Gastrointestinal @G7AB!$" !istended or scaphoidI 7ntestinal sounds nor+alI 4ain or

+asses on lightdeep palpation of FuadrantsI 8e'ound< guarding< or ascitesI Mc'urneyDspoint tenderness @for appendicitisI Liver span or gall'ladder tenderness @MurphyDsISpleno+egalyI HerniasI

Genitourinary @GU" Costoverte'ral angle @C3A tendernessI idney palpation nor+alIEternal genital ea+ or pelvic ea+ nor+al @only done if pro'le+ suspectedI

Musculoskeletal and neurological @MS&S" Li+' 'ulk< strength< tone< and refleesnor+alI !er+ato+al sensation and proprioception nor+alI Gait< coordination< and othernervous syste+ signs nor+alI Any der+atological concerns @e( rash< ulcer< vesicles< etc(or physical in>uries @e( lacerations< 'ruises< dislocations to 'e notedI

( 7&3ES 7GA 7$&S A&! LAB*$8

$ften patients #ill already have had so+e investigations ordered and possi'ly perfor+ed after theinitial e+ergency physician assess+ent already( This is typically 'lood#ork @e( CBC!<electrolytes< BU&< Cr< and +ay also include a chest ?ray @C8< ECG< urine dip< or urine toscreen( !ocu+ent these results on the consult for+ as #ell(

,, The CLE8SH74 GU7!E ; !ocu+entation



)6( 7M48ESS7$&

This is a state+ent su++ariing all the infor+ation availa'le thus far< and should include #hatone 'elieves the +ost likely diagnosis is @or if it canDt 'e differentiated at the +o+ent< and #hythis is or #hat this conclusion is 'ased on(E( JMr( Ed 7ssine is a :0 year old Caucasian +ale #ith a : year history of hypertension #ho presented to E! #ith co+plaints of chest pain that occurred an hour ago #hile he #as gardening< and lasted for roughly )6 +inutes( He descri'es that it #as an unco+forta'le pressure

on his chest that #as constant< #ith so+e of the sa+e sensation occurring do#n his left ar+( Healso had so+e shortness of 'reath and diaphoresis during that ti+e( The pain #ent a#ay after hesat do#n and rested for a #hile( An ECG and 'lood#ork including troponins has 'een orderedand is pending( Given the clinical info< the +ost #orrying diagnosis is acute M7< and #ill 'e+anaged as such #hile other possi'le differential diagnoses are ruled out concurrently(K

))( !7%%E8E& 7AL !7AG&$S7S

This section is #here you consider all possi'le conditions that fit the patientDs clinical picture< anddescri'e #hat evidence +ay or +ay not support each differential( *hat further investigations that

#illshould 'e done that could help to rule in or out specific diagnoses should also 'e noted here($rder the differential fro+ +ost likely to least likely< 'ut donDt 'e afraid to cast a #ide net using asyste+s?'ased approach or 37&!7CATE as a 'rainstor+ing aid( Although +any of theconditions you co+e up #ith +ay 'e clearly unlikely to 'e the case< your attending stillappreciates kno#ing you had considered this at the very least< and that you understand #hy itDs 'eing ruled out(

)/( 4LA&

7t is here that you provide a clearly delineated list of actions that are planned for the patient<

#hich should include the i++ediate care plan @e( ad+it vs discharge X? follo#?up inco++unity< and +ay include 'oth actual orders for investigations and +edications< general+edical care @e( J#ill +onitor hourly vitals for change in sta'ilityK< or non?+edical actions @e(J#ill liase #ith social #orker to arrange for co++unity housingK( 7f there is a foreseea'le coursein hospital< one can co++ent too on #hen epected date of discharge +ay 'e @e( Jpatient tostay for ,?0 days until UT7?induced deliriu+ resolves< then can 'e dcDd ho+e #ith follo#?up#ith fa+ily doctorK(

$nce co+plete< all consults should 'e revie#ed #ith a resident @if availa'le and attending todiscuss the plan and +ake any ad>ust+ents( 7n practicality< at the ,rd year level itDs unlikely for usto create the perfect correct care plan( 7tDs 'est to #rite up to the differential diagnoses< thendiscuss #ith the supervising residentattending regarding the plan 'efore you #rite it do#n(Ho#ever< 'efore revie#ing< you should for+ulate in your head a patient care plan and #hy< asthis is #hen staff #ill likely Fui you(




!epending on the service< there +ay 'e a reFuire+ent that all consults are dictated into thesyste+< even if the consult sheet has 'een #ritten out( Consultation dictations generally follo#the #ritten for+at de+onstrated a'ove in the eact sa+e fashion< 'ut are +ore fluid as co+pletesentences are spoken( Access to the dictation syste+ varies fro+ hospital to hospital< so check#ith the unit clerk or supervising doctor for instructions( -ouDll also need the dictation code ofthe attending staff doctor @unless youDve 'een assigned your o#n code( Begin every dictation#ith"JThis is @na+e< @,rd0th year MS7< dictating on 'ehalf of @attendingDs na+e( This is a

@dictation type< ie( consultation note on patient @na+e< then spell it out< patient 7! V @read itout( 4lease send copies to !r(@na+es of attending< referring doc< and ptDs G4K


Me+ora'le Mo+ents

Y*hilst on +y rural rotation +y >oke?loving preceptor told +e to go ea+ine a

) year old fe+ale #hose +other had YYdiagnosedYY her #ith pneu+onia andsent her to the e+ergency roo+( After conducting a thorough ea+ination 7returned to +y preceptor and stated< YYif she had pneu+onia 7Qll eat a fluorescentlight 'ul'YY(

YY$ne of those great long onesIYY he asked to #hich 7 affir+ed(

*e #ent 'ack to the patient and +y preceptor pointed at +e< looked at thepatient and said< YYhe says< if you have pneu+onia< he #ill eat a fluorescent light

'ul'(YY

,: The CLE8SH74 GU7!E ; !ocu+entation



777( Ad+ission orders

$nce the consult has 'een co+pleted< orders #ill need to 'e #ritten( As #ith the care plan<students should think ahead on the orders they 'elieve #ill 'e needed< then discuss #ith the

supervising staff and #ork through the orders together( Ad+ission orders can 'e su++aried asfollo#s @using the A!CA!A37! +ne+onic"

A

" Ad+it to !r( ZZZ< @specialty( *ho the attending is< and their service(

!

" !iagnosis( The leading diagnosis at the +o+ent< or the +ain sy+pto+ follo#ed 'y J&-!K ifnot yet diagnosed(

C

" Code status( Generally Jfull codeK< 'ut so+e senior patients +ay have a !&8 order or otheradvanced directives in place(

A" Allergies( *hat drug< food< or other allergies are there< and #hat happens if they are eposedto thisI

!

" !iet( *hat cancanDt they eat< and in #hat ti+efra+eI E( dia'etic diet< &4$ @nil per os<fluids onlyR after +idnight< until no nausea< etc(

A" Activity( *hat cancanDt they do< and in #hat ti+efra+eI E( AAT @activity as tolerated< 'edrest< progress to #eight?'earing as tolerated< etc

3" 3itals( Ho# freFuently should vitals 'e takenI E( vitals regular @note that this could vary

'et#een different services< ranging fro+ once per day< once per shift< or once per 0 hours<F,6+in< Fshift

7" 7nvestigations73( Any tests to 'e ordered< such as 'lood#ork< ?rays or other i+aging<urinalysis< etc( &ote that for 'lood#ork< so+e things need to 'e specifically na+ed out @e( JlivertestsK isnDt accepta'le< as it should actually 'e #ritten out as JAST< ALT< AL4< GGT< al'u+in< 'iliK( 73 solutions should also 'e ordered at a specified infusion rate for either replace+ent or+aintenance fluids @e( &S # 06+EF ClL at )66+Lhr(

!

" !rugs!irections( !rugs that need to 'e ordered include those that #eDre using to treat thepatientDs condition< drugs that the patients are taking nor+ally< and drugs that are useful for #hile

staying in hospital( 7n general< students should 'eco+e fa+iliar #ith the popular and freFuentlyused +edications for #hen patients are to 'e ad+itted( To consider possi'le needs for+edications< one can use the J1 4sK( So+e co++on options are also de+onstrated"




)(pain

@analgesics?revie# opiates #ithresidentsstaff. They all havetheir o#n preferences.

Tylenol ,/:?1:6+g 4$48 F0?1h 48& @+a( 0666+gday+orphine :?)6+g oral liFuid F0h 48& @hold if 88[)6hydro+orphone )?/+g 4$SC F0h 48& @hold if 88[)6

/(pus

@anti'iotics far too +any choices to list< 'ut consider it in ter+s ofcoverage for gra+X< gra+?< anaero'es< and atypicals

,(pillo#

@sleep opliclone ,(5:?5(:+g 4$ FHS 48&

0( puke @nausea Gravol /:?:6+g 4$SC73 F1h 48&+etoclopra+ide :?)6+g 4$73 F1h 48&ondansetron 0?2+g 73 F2h 48&

:(poop

@constipation J'o#el care protocolK @+ost hospitals have their o#n inplacelactulose ,6?0:+L 4$ @titrate dose freF( for /?, BMsday

1( personal +eds any +edications previously 'eing taken should 'e reorderedor patient can take o#n @this still reFuires an order to 'e#ritten out( 4har+anet reports can 'e helpful( Alsore+e+'er to H$L! any +edications you donDt #ant thepatient to take(

5th non?+ed J4K is JpeeK ? consider #hether the patient needs a foley @avoid if possi'le

So+e general rulestips"

!onDt forget that orders are #ritten one per line only.

Every +ed order reFuires the na+e @generic< dosage< route @ie( 4$< 7M< etc(< and thefreFuency @ie( daily< B7!< FHS< etc(( Also set li+its to the +ai+u+ daily doses if needed@ie( +a( 0666+gday of all aceta+inophen containing products

%ollo# good prescri'ing practices. This +eans not using JugK for +icrogra+s< nounnecessary trailing 6Ds< add leading 6Ds 'efore the deci+al< and avoiding easily +isreada''reviations such as $! or O! @#rite these out as Jonce dailyK(

!onDt forget to flag the orders on the chart @or #herever the unit #ants orders to 'e flaggedafter you #rite the+< or they +ight 'e +issed. %lagging orders +eans either pulling up asliding flag in the chart that says Y!octorQs $rdersY< or raisingputting up a flag or +arkerat the location #here the chart is kept(

%or any JstatKurgent orders< or co+plicated instructions< talk directly to the nurse first<then to the unit clerk< to ensure the orders are co+pleted Fuickly and accurately(




Even though it is up to the #riter to contact specific services for a consult @e( Addictions+edicine< or to help the patient @e( physiotherapy< these still 'enefit fro+ a #ritten order@e( Jaddictions +ed to see re" su'stance useK< as then the unit clerk can add the patient tothat servicesD rounding lists as a re+inder for that tea+ to see the patient(

!onDt forget to fill out any additional for+s that +ay 'e reFuired. ?rays and other i+agingusually reFuires a 8adiology reFuisition for+ to 'e filled< certain +edications +ay have aprotocol for+ @e( heparin< etc( The need for certain for+s vary fro+ hospital to hospital<

so itDs 'est to ask the unit clerk #hen unsure(





73( !ai ly progress notes and

orders

!aily progress notes should 'egin #ith a 'rief identifying info state+ent< follo#ed 'y a note inthe S$A4 for+at @Su'>ective< $'>ective< Assess+ent< 4lan( The 7! state+ent helps as a Fuickreference for future readers as to #ho the patient is< their reason for ad+ission< and their status upto no#(E( 4t is a :0 y(o( +ale ad+itted / days ago for chest pain diagnosed as angina< #ith acute M7ruled out( HeDs currently sta'le and has 'een started on aspirin and +etoprolol( A stress test isordered and is epected to 'e co+pleted today(

The S$A4 note docu+ents the patientDs current status< and outlines the upco+ing plan( Everypatient the student is responsi'le for reFuires a daily evaluation and S$A4 note to 'e co+pleted

in the course of rounding( A''reviated S$A4 note updatesaddendu+s can 'e #ritten as plansare revie#ed #ith supervising staff or residents< or as certain tasks are co+pleted(E(Update" revie#ed patient #ith occupational therapist and dietitian regarding lifestyle changesfor lo#ering B4 and cholesterol( They #ill see patient today(

Any orders to 'e done can 'e #ritten as a nu+'ered list on the physician orders sheet< signednoting #ho itDs 'een discussed #ith< and then flagged as a ne# order( As +entioned a'ove<flagging orders +eans either pulling up a sliding flag in the chart that says Y!octorQs $rdersY< orraisingputting up a flag or +arker at the location #here the chart is kept( As noted< for anyJstatKurgent orders< or co+plicated instructions< talk directly to the nurse first< then to the unit

clerk< to ensure the orders are co+pleted Fuickly and accurately( !epending on the hospital orrotation< orders +ay reFuire a co?signature for all orders 'y staff or a resident @e( pediatrics<#hile other services +ay not care if +ed student orders are co?signed as long as it notes #ho it#as discussed #ith @e( 4sychiatry(


, The CLE8SH74 GU7!E ; !ocu+entation



3( !ischarge dictations and

su++aries

*hen a patient is discharged< a dictation should 'e co+pleted to docu+ent the course of thepatientDs diagnosis and treat+ent in hospital< as #ell as to share this infor+ation #ith theprofessionals involved in follo#?up care( Although +any si+ilar ele+ents of the initialconsultation dictation are shared< they are rearranged into a different for+at as follo#s @note thatthis can vary depending on the hospital site and attending preference for discharge dictations< soask #hen in dou't"

4atient identifying infor+ation and reason for ad+ission

Most responsi'le diagnosis

4re?ad+ission diagnoses @ie( +edical history

4ost?ad+ission diagnoses @ie( any other diagnoses +ade in hospital in addition to theJ+ost responsi'le diagnosisK<e( C(diff infection

Code status

$perative interventions @eg( intu'ation< central lines

&a+es of relevant specialists @list your attending here #ith the na+e of their service< along#ith any other specialists that #ere consulted during the patientDs stay in hospital< eg( !r(House< nephrology

Allergies

Medications on discharge

4ost?discharge follo#?up @ie( #hatDs the plan after dischargeI

!ischarge disposition @i(e( #here they have 'een discharged to( %or +ost patients< this #ill >ust 'e Jho+eK< 'ut it could 'e a nursing ho+e< a fa+ily +e+'erDs care< etc(

Treat+entcourse in hospital @this is #here you give a short narrative a'out #hat happened#hile the patient #as in hospital

*hen you are dictating< you need to state eactly #hat you #ant to have #ritten on the finalpaper su++ary( So< for ea+ple< after stating your na+e and the proper introduction as outlinedearlier< you #ould say" J&e# paragraph heading( Most responsi'le diagnosis( Colon( &e# Line(C$4! eacer'ation( &e# paragraph heading( 4re?ad+ission diagnoses( Colon( &e# line( 7n listfor+ please( $ne< non?insulin dependent dia'etes( T#o< hypothyroid( Three< left 'reast cancer#ith +astecto+y in /66( &e# paragraph heading(((K and so on< #hich #ill co+e out on paperlooking like this"

06 The CLE8SH74 GU7!E ; !ocu+entation



Most responsi'le diagnosis" C$4! eacer'ation4re?Ad+ission !iagnoses" ) &on?insulin dependent dia'etes/ Hypothyroid, Left 'reast cancer #ith +astecto+y in /66Etc(((

!ictating can 'e a 'it unpleasant and difficult to get used to< so get a resident to #alk you throughit the first ti+e( 7f you can< listen to so+eone else do a dictation 'efore you atte+pt one(


0) The CLE8SH74 GU7!E ; !ocu+entation



37( 4rocedure notes and orders

%ollo#ing any procedure @surgical or other#ise< a note should 'e #ritten to docu+ent theoperationprocedure and findings< as #ell as a set of orders for #hen the patient is ad+itted tothe #ards @or ne# +anage+ent reFuire+ents post?procedure( Both these types ofdocu+entation provide a good opportunity for students to 'e involved +ore in patient care< help

out the resident< and learn +ore a'out +anage+ent( 4rocedure notes +ay vary< 'ut the generalsurgical $8 note has the follo#ing"

Surgeon" #ho the pri+ary surgeon@s #as#ere< and #hat specialty they #ereI

Assists" #ho the assisting staff #ere @e( residents< MS7s< G4 assistsI

Anesthesia" #ho the anesthetist #as @look on the $8 'oard or ask the nurses if you havenDtcaught the na+e already during the $8I

4rocedure" #hat surgery #as done @hopefully you listened< 'ut can also look on the $8slate sheet< and using #hat +ethod @e( laparoscopic< open< etcI

4re?op diagnosis" #hat #as the preli+inary diagnosis pre?surgeryI

4ost?op diagnosis" #hatDs the diagnosis after the surgery< #hich +ay not al#ays 'e the sa+eas pre?op< depending on findings(

%indings" #hat #as o'servedfound in the $8< and #ere there any sa+ples taken and sentto the pathology la' @or other depart+entsI

Co+plications" #ere there any unepected events or findings during the procedure< and#hat #as done in regards to thisI

Esti+ated 'lood loss" #hatDs the 'est guess at the a+ount of 'lood the patient lostI Look atthe suction canisters to guessti+ate< 'ut re+e+'er to account for any other fluids such assaline rinses( 7f the a+ount #as relatively +ini+al< [:6+L is a reasona'le EBL( 7f youDre#riting anything greater than the ,66?066+L range< definitely discuss #ith your resident orattending first.

!isposition" ho# #as the patient #hen heshe left the $8< and #hatDs the plan for the+afterI Sta'le< a#ake< +ovingI Ho# long is it epected for the patient to 'e in the post?anesthetic recovery roo+I

$ften pre?printed post?operative order sets are availa'le to 'e filled in( They structuralie aspectsof post?surgical care and list a nu+'er of co++only used +edications @e( heparin< analgesics<anti?nauseants that can have its 'o ticked off as needed( Although they can appear co+plicated<theyDre relatively straightfor#ard< 'ut certainly #ork #ith the staff or resident to go through theseorder sets( 7f orders are hand#ritten< consider it like doing a full set of ad+ission orders again#ith A!CA!A37!< in #hich all their pre?operative +edications need to 'e re?#ritten< along#ith any ne# +edications they should receive(


0/ The CLE8SH74 GU7!E ; !ocu+entation



377( Specialty specific

aspectsco+ponents

Certain specialties have additional focused sections of a co+plete history that is uniFue to theirfield< and thus these co+ponents should 'e ad>usted as appropriate(

$BS E 87CS

7n o'stetrics< there is +ore than one patient to 'e concerned #ith during the intervie#( Ouestionsneed to 'e asked regarding 'oth the #o+anDs health and current condition< as #ell as that of the 'a'yDs( Any consult or history on a pregnant patient +ust include key infor+ation such as thegestational age of the 'a'y and if any co+plications have arisen so farI 7n the acute setting #hena +other presents to the hospital stating theyDre in la'our< one can Fuickly deter+ine the urgency

#ith 0 key pieces of infor+ation"

Contractions" *hen did they startI Ho# strongpainful are they fro+ ) to )6I Ho# farapart are the contractionsI Are they 'eco+ing strongerI

Me+'ranes" Have you felt a gush of fluidleakingda+pness in your under#earI Has yourJ#aterK 'roken @if itDs not her first pregnancyI *hat colour #as itI

Bleeding" Has there 'een any 'lood or spotting on your under#earI Ho# +uch is it if thereisI *hat colour #as itI *as it liFuid or clotsI

%etal +ove+ents" 7s 'a'y still +oving the sa+e a+ount as youDre use toI 7f itDs less< ho#

+uch less or ho# long 'et#een +ove+entsI

$n top of the nor+al history co+ponents< it is also i+portant to o'tain a thorough o'stetrics andgynecological history for any presenting patient< #hich includes the follo#ing infor+ation"

$'stetrical History" Ho# +any #eeks pregnant are youI 7s this 'ased on LM4 or a dating ultrasoundI !id theultrasound sho# anything a'nor+alI Ho# has the pregnancy 'een thus farI Any co+plicationsor pro'le+s< such as spotting'leeding @ho# +uch#hen< or +a>or illnesshospitaliation @#hatand treat+ent receivedI *hat ea+s or screening has 'een done alreadyI Blood testsI Group BStrep and other ST7 screenI Any concerns like high 'lood pressure @gestational hypertension or 'loodurine sugar @gestational dia'etesI 7s this your first pregnancy @GT4ALI Ho# #ere theprevious pregnancies and deliveries @+ethod and ter+I *hen and #here #ere theyI Anyco+plicationsI *as instru+entation @e( forceps or vacuu+ or a c?section reFuired< and #hy

0, The CLE8SH74 GU7!E ; !ocu+entation



Gynecological History @not all Fuestions are appropriate. Tailor to the patient" *hen #as your LM4< and #hat #as the character of itI *hatDs your nor+al +enstrual cycle like< 'oth on and off $C4I Ho# long is your cycle< and ho# regular is itI Ho# +any days is the+enstruationI *ould you descri'e your flo# as heavy or lightI Ho# +any padsta+pons do youneed to change in a typical day of +enstruationI Any cra+ping or pain #ith +enstruationI Any4MS sy+pto+sI 7f post?+enopausal< #hen did your period stop< and has it 'een consistentlygoneI Any associated sy+pto+s such as hot flashes or irrita'ilityI Any hor+one replace+enttherapy @H8T 'eing takenI Any cancersI

Are you currently seually activeI 7s it a steady partner< or +ultiple partnersI 7f a steady partner<ho# long< is the relationship doing #ell< and are there any concerns of infidelity regarding yourpartnerI Ho# +any partners have you had in the last 1 +onthsI !o you have se #ith +en<#o+en< or 'othI Any pain during seI !o you feel safe< or have you ever felt threatened orhar+ed in seual encountersIAre you currently using any for+ of 'irth controlI 7f $C4< #hich one< #hen did you start takingit< ho# has it 'een< any side effects< do you ever forget to take pills< and #hat do you do if thathappensI 7f 7U!< #hich one< #hen #as it inserted< ho# has it 'een for you< and do you still use 'arrier protectionI 7f 'arrier protection or other +ethod< ho# consistently is it done< and ho# doyou feel a'out itI

Any history of ST7I *hich one< and #hat #as done a'out itI !id any co+plications result fro+that episode or currentlyI *as it reported and the source traced 'ackIAny previous surgeries of a gynecological natureI *hat and #henI Any co+plications resultingfro+ the+I Ho# do you feel no# a'out itI




4S-CH7A 8-

7n general< psychiatry patients have already 'een +edically cleared 'y the e+ergency doctor< orhave a hospitalistG4 overseeing their general health #hile they are an inpatient( As such< +anypsychiatric consultations do not reFuire a full physical ea+< and instead can 'e su++aried#ith the last vitals taken< then stating that theyDre sta'le and have 'een +edically cleared already(7nstead< the physical ea+ should 'e replaced #ith the +ental status ea+ @MSE< theo'servational eFuivalent of the physical ea+ for the +ind( The MSE is su++aried 'y the

+ne+onic 7AMSE4T7C"

7

7dentifying info 4atientDs actual age< apparent age< ethnicity

A

Appearance of the patient 4hysical appearance< including nota'le features @e( facial haiscars< etc and 'ody ha'itus( Hygiene and appearance ofhealth( Clothing #orn< style< cleanliness< appropriateness(

M

Manneris+s and +otoris+s Body language and position @e( relaed< tensed< slouched<etc( Use of hand gestures or other 'ody +otions(4sycho+otor agitationretardation( A'nor+al +ove+entpatterns @e( posturing< chorea< tre+or< etc(

S

Speech usage and patterns Speech rate< rhyth+< prosody< tone< volu+e< a+ount< range<spontaneity< coherentnon?sensical( &eologis+s< s#earing<rhy+ing< clang associations< vocaliations< +istaken #ord use

E

E+otional affect and +oodstate

Affective state @e( euthy+ic< happy< sad< angry< anious< etc(Affect sta'ilityla'ility< range< and congruency to +ood( Mooas stated 'y patient or inferred fro+ intervie#thoughtcontent(

4

4erceptions Hallucinations @e( auditory< visual< tactile< olfactory<gustatory< illusions< depersonaliation< derealiation(

Thought content andprocess 4rocess organied and logical< goal?directed< circu+stantial<tangential< loose associations @X pressured speech W flight ofideas< #ord salad< illogical< disorganied and illogical(Content +ay include delusionsideas @e( grandiose<persecutory< paranoid< etc< o'sessions< +agical thinking< ideaof reference< suicidal ideation< ho+icidal ideation(

7

7nsight< relia'ility< and >udge+ent

7nsight intactfull< +oderatepartial< +ildli+ited< none(8elia'ility of patient as historian and other +a>or events(=udge+ent good< +oderate< poor< none(

C

Cognition and +e+orystatus Cognitively intactalertoriented< disoriented< delirious< anyde+entia present< and +e+ory function like this( Generalassess+ent of patientDs intelligence and overall status(

0: The CLE8SH74 GU7!E ; !ocu+entation



4atient assess+ents reFuire a +ulti?aial diagnosis< uniFue to psychiatry"

Ais 7"

any psychiatric disorder< including su'stance induced conditions< 'ut ecluding ais 77diagnosesAis 77"

personality disorders and +ental retardation deficitsAis 777"

general +edical conditions @not directly affectingcausing ais 7 diagnosesAis 73"

socialenviron+ental factors< that affect or are related to the psychiatric diagnoses<including stressors'arriers to treat+entrecovery

Ais 3" glo'al assess+ent of function @GA% score< ranging fro+ 6?)66( 8efer to other resourcesfor the 'reakdo#n of score ranges( 7n general< any score less than 06?:6 reFuires ad+ission forhospital +anage+ent

The 'iopsychosocial +odel of patient +anage+ent consists of"

Bio"

psychiatric +edications or treat+ents that #ill i+prove the patient condition< such as anti?depressants< anti?psychotics< aniolytics< or electroconvulsive therapy4sycho

" psychoeducation @teaching the patient and fa+ily a'out the diagnosed condition and+anage+ent epectations< psychotherapy @e( cognitive 'ehavioural therapy< outpatientpsychiatrist and +ental health tea+ care

Social" assessing and alleviating stressors @e( fa+ily situations< social #orker assess+ent<housing and safety< financial +anage+ent< occupational issues< drug reha'ilitation< caregiverfatigue +anage+ent




AM4LE H7S $8- @EME8GE&C-

There are situations in #hich a co+prehensive history is either not practical or necessary< eitherli+ited 'y ti+e or situational constraints( %or ea+ple< a critical patient co+ing into e+ergencythat reFuires urgent surgery( 7n place of a full history that can 'e taken later< an AM4LE history+ay 'e done instead( The acrony+ covers pertinent infor+ation for patients that reFuiree+ergent care< and stands for"

A" Allergies To prevent ad+inistering drugs that could have adverse reactions

M" Medications To consider drug interactions< and as collateral for 4MH

4" 4ast +ed H To deter+ine general health and sta'ility for procedures

L

" Last +eal To assess risk for aspiration if patient reFuires intu'ationsurgery

E

" Events To understand #hat happened to the patient leading up to no#

This Fuick si+ple history can yield a significant a+ount of infor+ation< and can also 'e takenfro+ partners or fa+ily +e+'ers co+ing in #ith the patient #ith relative accuracy if the patient

is unresponsive the+selves( Ho#ever< it is never an adeFuate per+anent replace+ent for aco+prehensive +edical history< and this should 'e co+pleted at the first availa'le opportunity<either through collateral +edical records or the patient the+selves once sta'ility has 'eenachieved(





H$* $ $4E8A E 7&

SU8GE8-



Being a Med Student in the $8" 7ntroduction(((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (0

7( %inding the $8((((( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( :6

77( Costu+e change @scru's((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( :)

777( %irst steps((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( :/

73( Scru''ing in(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((:,

3( Suiting up @go#n and gloves((( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ::

37( aking your position(((( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( :5

377( eeping it clean @steril ity protocols(( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (:2

3777( Helping out @retracting< cutting< staplingsuturing((( ( ( ( (16

7( Cleaning up(((( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 1/

( *ash< rinse< and repeat ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 1,

02 The CLE8SH74 GU7!E ; Ho# to $perate in Surgery



Being a Med Student in the $8"

7ntroduction

&o< +edical students are certainly not epected to kno# ho# to co+plete full operations< noreven 'e a'le to identify every single part of the internal anato+y during a particular surgery(Ho#ever< they are epected to kno# ho# to handle the+selves in the operating roo+ and

surgical field< often #ith little instruction or orientation other than the ) to / hours of teachinggiven during the first #eek of ,rd year( As a result< +any students find the+selves lost< confused<and too anious to gain as +uch as they could fro+ the eperience of 'eing in the $8 itself(

This sectionDs ai+ is to relieve so+e of that aniety 'y orienting ne# students to surgery etiFuette<epectations< and general advice< #hile avoiding co++on pitfalls( 7t is organied in order of a

typical $8 day eperience< and descri'es #hat to epect in each step of the process( Althoughnot every $8 is the sa+e< nor every surgical specialty< in general +uch of the infor+ation here isco++on to any eperience in this so+e#hat ne# and foreign land(





7( %inding the $8

Before entering the $8< you +ust find the $8( Luckily< the +a>ority of $8s at hospitals happento 'e located on the /nd floor @7D+ sure for so+e logistical reason un'ekno#nst to +e( So a

good 'et is to head there first and look for the signs( 7f you 'eco+e lost< si+ply ask anyone#earing scru's @alternatively< you could follo# the+ around creepily until they lead you to the$8< 'ut this is far less efficient( -ouDre looking for either so+e kind of front desk #here $8 'ooking is so you can ask for instructions< or an un+arked door #ith so+e kind of keycard ornu+pad lock on it that leads to the change roo+s @although 'e careful as un+arked doors arenDtgender?differentia'le( $nce you +anage to get into the change roo+< youDll 'e ready for the netstep 'efore heading into the $8s >ust past the far change roo+ doors(


Me+ora'le Mo+ents

7 #as in +y peds rotation @second #eek of third year #orking in the &7CU( My preceptor and 7 #erecalled to a stat c?section( Being ne# to the $8 scene 7 did not kno# #here to find things or #hat to gra'running in( As #e ran into the $8 hall#ay< +y preceptor handed +e #hat 7 thought #as a cap and said<Y4ut this on your head(Y 7n / +inutes the entire hall#ay full of nurses< doctors and one nervous daderupted in laughter( Apparently< there are 'eard covers you can #ear in the $8< and #hile they lookstylish< they should not 'e #orn on your head(

:6 The CLE8SH74 GU7!E ; Ho# to $perate in Surgery



77( Costu+e change @scru's

More than >ust a funny T3 sho# or so+ething a 6Ds 89B girl group does not #ant< scru's areFuintessential to surgery( They co+e in a +ultitude of sies differentiated 'y the colours of the

tri+ and dra#string @+ost #ill opt for the yello# s+alls or 'lue +ediu+s< they are reno#ned fortheir pa>a+a?like co+fort< especially for #hen on call( They usually co+e in a dra' green or 'lue< are sta+ped #ith a fading health authority logo< and can 'e found nicely folded in stacks ona +etal rack in the change roo+( So< gra' a pair @ensuring you donDt get / tops or / 'otto+s< aneasy +istake and change it up(

Scru's can 'e #orn over light shirts and under#ear or< for those of you #ho prefer co+pleteco+fort< over nothing at all @if you can cope #ith the fact scru's see a lot of s#eat< 'lood and#ho kno#s #hat else during their lifeti+es< even if they are thoroughly cleaned each ti+e(So+ething to keep in +ind a'out 'eing a loose?fitting gar+ent< is that +odesty +ay so+eti+es 'e of concern #hen leaning over #hile in scru's< and thus opting for a s+aller sied top +ay 'e

prudent @or as so+e nurses choose to do< using silk tape to secure their v?neck closed( Scru's arereversi'le< so donDt fret a'out putting the+ on inside out( Typically ,?0 pockets are availa'le forkeeping your valua'les @e( keys< #allet< cellphone or other tools @e( pen< paper< pager<stethoscope close to your 'ody( Leave the rest of your stuff in or on top of a locker in thechange roo+ as they arenDt #elco+e in the $8(

To co+plete the transfor+ation< the scru' outfit reFuires a cap and shoe covers( Caps co+e in /types< JsurgeonDsK and Jsho#erK( -ou +ay feel a little pretentious to don the JsurgeonDsK stylecap early on< 'ut there isnDt really any rule in regards to this( Most people opt for the Jsho#erKcap though si+ply 'ecause itDs the only one that can cover all of your glorious +ane( !onQt

forget shoe covers< especially for inherently +essier specialties such as $'sGyn and G7 surgeries(=ust in case< itDs pro'a'ly still 'est to #ear an older pair of runners than your 'rand ne# kicks(A+niotic fluid or 'lood isnDt shoe friendly(


:) The CLE8SH74 GU7!E ; Ho# to $perate in Surgery



777( %irst steps

$nce youDve gotten changed< itDs ti+e to head into the unkno#n( Most operating #ings arearranged in a sFuare or rectangular lay?out #ith the various $8s surrounding a central supply

core( ThereDll 'e plenty of signs around indicating #here the various nu+'ered $8s are( 7f youalready kno# to #hich $8 youDre headed< then you can go there directly< even if you accidentallytake the long #ay around the sFuare( 7f youDre not sure #hich $8 youDre supposed to 'e in< findan $8 slate print?out posted so+e#here @often on $8 doors and figure out #hich roo+ yourspecialty service or surgeon is in( &o# you can head there and youDll pro'a'ly also the long #ayaround @inevita'le(

Before you enter the $8< look through the #indo# to see if thereDs already a surgery in progress(7f yes< +ake sure you put on a face+ask 'efore you head in< or youDll Fuickly 'e turned a#ay 'y

the nurses( 7f the roo+Ds still 'eing set?up or is in changeover +ode 'et#een surgeries< head in(Bring a face+ask >ust in case< as technically if sterile eFuip+ent has 'een cracked and is 'eing

set?up< youDre still a conta+ination haard 'y the nurseDs 'ook(

A Fuick aside on face+asks" there are a variety of choices availa'le< 'ut in the end itDs all a'outco+fort( The ones #ith the attached faceshields can 'e useful for those #ho donDt already #earglasses< 'ut re+e+'er to crease the edges for#ard< lest you en>oy having plastic adhered to yourforehead s#eat for hours during the surgery( Alternatively< you could al#ays #ear the disposa'leplastic sheet glasses availa'le( 8egardless of the style< ensure you pinch the +etal strip at the 'ridge of the nose for a good fit @especially if you #ear glasses< other#ise itDll 'e like drinking hotsoup(((

7f the surgeryDs on< >ust enter Fuietly and stand 'y the side until youDre noticed 'y the surgeon andare addressed( 7ntroduce yourself as the surgery +edical student< and that youDve 'een assignedto this $8 or that doctor for the day( TheyDll then provide further directions a'out #here to standfor the 'est vie# @often 'y the head #here the anesthesiologist stands< 'ut 'e sure to not o'structhisher #ay( The surgeon #ill usually also give a 'rief 'lur' a'out the current patient andprocedure( Be prepared to 'e asked Fuestions during the surgery as youDre #atching.

7f the roo+Ds 'eing set?up 'y the /?, nurses @) scru' nurse and )?/ circulating nurses< introduceyourself and put your na+e on the 'oard along #ith your glove sie @+ore on this later( Check#ith the nurses regarding #ho the net patient #ill 'e @the slate order is so+eti+es changed up<

and read the chart for the patient history( 7f thereDs even enough ti+e to do so< you +ight evenuse the co+puter or a reference 'ook to look up so+e relevant anato+y and surgical steps of theplanned procedure(


:/ The CLE8SH74 GU7!E ; Ho# to $perate in Surgery



73( Scru''ing in

At so+e point during your eperience in the $8< the attending surgeon #ill offer you the chanceto scru' in< either to assist or for a 'etter vie# of the operation( There #ill 'e no reason for you

to ever decline @even if you #ant to< so 'e prepared to get sterile and >u+p in on the action(*hen you do get the chance to scru' in< the first step is to let one of the nurses kno# youDll 'escru''ing in so they can gra' an etra go#n set< and then you should go into one of theca'inetsdra#ers to gra' gloves in your sie and open the+ for the scru' nurse to take(

Scru' areas are outside each operating roo+< and a variety of scru' products can 'e found placedor +ounted a'ove the scru' sink( The faucets #ill either have a +otion?activated sensor< or #ill 'e controlled 'y the U?shaped s#itch 'elo# the sink @you use your leg to turn this onoff( 7ngeneral< there are t#o +ethods of scru''ing in< each #ith their o#n pros and cons"

) CHL$8HE7!7&E $8 $ HE8 A& 7SE4 7C T*E D SC8UB

Method"

%irst gra' a scru' pack< open it< and i++ediately toss a#ay the nail pick( 3ery rarely#ill this 'e needed< unless you have very long nails< you #ere >ust #orking in the garden< or you >ust finished +ining for goldD in your nose?cave @e#I< and have very visi'le dirt under the nails(

7f so< do keep the nail pick to clean out the gunk fro+ 'eneath each nail( 8e+ove any rings<#atches< or 'racelets fro+ your hands 'efore you start(

&et< #et your hands and the Chlorheidine sponge< and use it to lather up your hands andforear+s( Then flip it over to the scru''y side< and give yourself a nice efoliation treat+ent(!onDt +iss any spots( This +eans scru''ing each of the 0 surfaces of each finger< as #ell as the

fingertips and fingernails< the 'ack and front of each hand< and all 0 surfaces of each forear+ allthe #ay to a'ove the el'o#( This should take you at least a +inute and a half to do properly @anyless and youDre cutting corners(

&o# for the trickiest part" the rinse @#here +ost +istakes occur( -our hands should 'e raised to 'e a'ove your el'o#( Under the running #ater< run your hand through the strea+ #hile stillkeeping your ar+ angled up @el'o#s do#n< and ru' the fingers of that hand together to get thesoapy 'its off( Carry on rinsing do#n your hand< #rist< then forear+ until you get to your el'o#(&o# repeat the sa+e #ith the other side(

8e+e+'er< ar+s are al#ays tilted up #ith hands a'ove el'o#s< do &$T accidentally touch thefaucet #ith your raised hand #hen youDre rinsing do#n to the el'o#< and definitely !$ &$Tgra' paper to#els after the rinse to dry off @nor+al ha'its can +ess you up( Mess up #ith anyof these< and youDll get the chance to practice the #hole thing over again @+andatorily.

4ros"

Can get under the nails and clean the fingertips #ell( Efoliation( Allo#s for +oretalk ti+e at the scru' sink( Makes you feel like a surgeon to do it the classicD #ay(

:, The CLE8SH74 GU7!E ; Ho# to $perate in Surgery



Cons" Can 'e harsh on the hands after +ultiple scru's( As a #etD scru'< it reFuires anetra step 'efore suiting up in your go#n and gloves( *astes #ater(

/ !E8M$ A& A&! MA&$8A47! T!8-D SC8UB"

Method"

This is a co+'ination +ethod< in #hich you first #ash your hands using !er+otan

soap to re+ove any gross conta+ination and dirt( This step usually only needs to 'e done onceat the start of the day< and only repeated if hands 'eco+e visi'ly soiled or you leave the $8 #ingand go to other areas of the hospital( -ou can use a si+ilar +ethod as the Chlorheidine+ethod< 'ut you donDt need to 'e as +eticulous in scru''ing every surface of your hands @'ut do+ake sure you get under the nails< and use a nail pick if necessary(

$nce your hands are cleaned< dry the+ off #ith paper to#els< #hich you A8E allo#ed to do inthis +ethod< and in fact should do Fuite thoroughly @residual #ater dilutes the solution in thenet step(

4u+p ,?0 sFuirts of Manorapid alcohol solution fro+ the dispenser into the cupped pal+ of one

hand( !ip the fingers of the other hand into the handful of Manorapid< then ru' the handfulonto the front and 'ack of the hand< and around each finger and the #rist( Use your still uncleanel'o# to pu+p a fe# +ore sFuirts into your cleaning hand< and use that to ru' do#n the forear+to past the el'o#( 8epeat #ith the other side 'y using your unclean el'o# to pu+p into the no#sterilied hand< clean the hand and ar+ up to the el'o#< then using the el'o# take the last fe#pu+ps to do a final clean of your hands(

Air dry #ith your ar+s held a'ove the #aist( -ou +ay see so+e doctors #ave their handsaround to speed up drying process< and although this isnDt likely a 'ig issue< one could argue thisincreases the conta+ination risk 'y generating air tur'ulence that could stir and pick up +ore

dust'acteria in the air( Safer to >ust let your ar+s air dry @or do very s+all #aves rather than 'ig+otions(

4ros"

Ouicker( Less harsh on your hands than repeated #ashing through the day( !ryDscru' +eans no need for the to#elling dry step 'efore you go#n up(

Cons" Manorapid s+ells Fuite strongly of alcohol and can +ake so+e of you #ooy ifyou inhale too +uch( 7f you have any open cuts or #ounds on your hands or ar+s(((o#(





3( Suiting up @go#n and gloves

$nce in the $8< head to#ards the scru' nurse to put on your surgical go#n and gloves( Ascourtesy< #ait your turn until the surgeon and resident are go#ned up 'efore you do @unless

theyDre still outside scru''ing in( The scru' nurse #ill open up your go#n and present it to you<so stick your ar+s into the sleeves< 'ut !$&DT put your hands all the #ay out of the cuffs. Thecirculating nurse #ill then 'utton your go#n at the neck and tie the inside strings at the 'ack(

Mean#hile< the scru' nurse #ill 'e stretching open your right glove for you< so stick your hand in#hile at the sa+e ti+e pulling your sleeve up so your hand slips through the cuff into the glove(!onDt #orry if you +iss the correct glove finger holes at this point< >ust leave it 'e for no# @to

date +y perfect gloving record only happens )6 of the ti+e still( *hen the scru' nursestretches the other glove open for you< pull it open even #ider #ith your glove hand to put yourre+aining hand in @again likely +issing the correct finger place+ents(

&o# you can ad>ust your gloves #ith your hands to +ake everything fit right< and pull on yoursleeves to get the+ out of your hands #ay @'ut donDt pull the+ past the gloveDs cuff< youDre tryingto for+ a tight clean seal there. 8epeat the #hole process if youDre #earing +ore than one pairof gloves( 7f youDre #earing a disposa'le paper linen go#n rather than a typical cloth go#n< 'ecareful you donDt pull too hard on your sleeves #hen ad>usting< 'ecause you CA& tear the go#n@7Dve done this 'efore((( and this #ill result in you having to rescru' all over again @along #ith aso+e#hat annoyed nurse and an e+'arrassed you(

$nce youDre all set and your gloves are co+fy< the last step is to tie up your go#n co+pletely @thisis a co++on step to forget to do< at least it #as for +e( ThereDs a card'oard tag at the front of

the go#n holding the front strings( 4ull this apart #ith 'oth hands< one hand holding onto theshort string< the other hand holding on to the tag( Give the tag to so+eone< usually the scru'nurse< 'ut if sheDs 'usy the circulating nurse can do it< as long as you leave a large portion of thecard for her to gra' on to( -ou then spin in the direction that #raps the tagged string aroundyour 'ack to close the go#n around you and 'rings the string 'ack to your frontside @usuallycounterclock#ise spin to your left( Gra' the tagged string as the nurse pulls the tag off< and tieto the short string youDve 'een holding onto this #hole ti+e( The key to the #hole process is tonot let any of the strings drop 'ecause you didnDt hold onto it at the appropriate ti+es( $nceco+pleted< youDre ready to get in position(

:: The CLE8SH74 GU7!E ; Ho# to $perate in Surgery



HereDs a Fuick seg+ent on glove sie and choice( Typical sies range fro+ 1s to )6s<corresponding to hand sie( So+e $8s #ill have a glove siing chart posted< 'ut if you donDt seeone youDll have to play it 'y trial and error( There are also half sies to 'etter fit hands< so try afe# ti+es #ith different sies until you find the right one for you( %or reference< as a guy #ithaverage sied hands and fingers< 7 #ear sie 5(:( They also co+e in 'ro#n or #hites< #hichgenerally corresponds to hand shape @'ro#ns generally have longer finger to pal+ ratio than#hites do( 7f thatDs not enough< they also co+e in different +aterials< such as late< vinyl< or&eoprene @for those #ith late allergies( Therefore you should test out different gloves #hen

you get the chance to find #hatDs right for you(

ThereDs also the Fuestion of #hether to #ear / pairs of gloves or )( So+e surgeons opt for t#o<partly 'ecause it provides for +ore safety in case the outer pair is cut or torn< 'ut also forconvenience since if the outer pair 'eco+es conta+inated so+eho#< they can pull that pair offand put on another glove #ithout having to scru' out as their hand is still covered 'y the sterileinner glove( Those #ho opt for only ) pair prefer it as itDs less hassle< and offers +ore sensitivityand control to their hands if they need it( So+e choose to #ear a pair of clear plastic liners onthe inside of an outer pair of surgical gloves< out of preference and co+fort( Typically the outerpair of gloves #ill 'e a half sie larger @or 'e a pair of 'ro#ns versus the inside pair< if opting to

#ear t#o pairs( There is no right or #rong to this< and co+es do#n again to personal preference(7 choose to #ear only ) pair of 5(: #hites< partly out of convenienceco+fort< 'ut also 'ecause 7

have enough trou'le getting one pair of gloves on s+oothly< let alone t#o(((





37( aking your position

After youDre go#ned and gloved< keep your sterile hands crossed on your ar+s or gripping thefront of your go#n( *ait until the surgeon and assistresident has prepped the surgical area and

draped the patient( $nce theyDve done so and have stepped into place at the ta'le< theyDll usuallydirect you to #here the 'est place for you to stand is( 7n general< only 0 fit easily around theta'le< and the scru' nurse needs their roo+ as #ell< so at ti+es you +ay find yourself furtherfro+ the surgical field or vie#ing fro+ a so+e#hat a#k#ard position( 7f you have a space to doso< put your 'ody right up against the ta'le edge< and your hands on the drape(

So+eti+es you +ay 'e asked to +ove or s#itch to the other side of the ta'le( *hen this occurs< 'ack yourself a#ay fro+ the surgical field #ith your hands crossed on your ar+s or held up< andshuffle around( -our front should al#ays 'e facing the sterile field< unless you need to cross 'ehind so+eone< in #hich case spin so your 'acks are facing each other and you can +ove intoposition on their other side( 7f you ever need to go around eFuip+ent to get to the other side<take the long #ay around< and &E3E8 cut in front of a scru' nurse and hisher surgicalinstru+ent ta'le @thatDs the Fuickest #ay to a repri+and fro+ the+(





377( eeping it clean @sterility

protocols

ThereDs a lot of easy +istakes to +ake #hen it co+es to 'reaking sterility< and itDs near inevita'lethat you +ay trip up at so+e point or other @7Dve certainly done it +ore than once(((( The +osti+portant rule of thu+' is Jthink 'efore you touchK( Ask yourself 'efore you touch anythingne#< Jis this sterileIK $ther principles include sterile heights< #hich is set at the highest point onyour go#n that has 'een 'elo# ta'le level at so+e point( This +eans if you sat do#n for a partof a procedure< you arenDt allo#ed to stand 'ack up over the field< as your upper 'ody is no#conta+inatedD 'y 'eing 'elo# ta'le level( Si+ilarly< anything 'elo# the #aist is regarded as non?sterile< so donDt ever let your hands drop do#n to your sides(

7tchiness< slipping glasses< or s#eaty foreheads also pose a co++on dile++a( -ouDre certainly

not allo#ed to use your shoulder to scratch that itch< push up your fra+es< or #ipe the forehead(7n these situations< you either tough it out< ask for help< or get innovative( Try fidgeting a 'it to

scratch against your go#n< or #rinkling your nose to get so+e face+ask friction to ease a noseitch( 7f neither +ethod #orks< >ust ignore it and likely itDll go a#ay on its o#n( 7f not< youDll haveto ask the circulating nurse to help you out 'y scratching< or si+ilarly pushing up your glasses or#iping your forehead( This can 'e a little e+'arrassing< 'ut thatDs #hy it helps to have 'een inthe roo+ earlier and have introduced yourself to the nurses 'efore the surgery( 7n ter+s ofinnovation< so+e have used various o'>ects in the roo+ to aid the+< such as pushing your glassesup using the edge of a tv +onitor or cart< as long as you donDt touch it #ith your go#n( -ou +ayget #eird looks or teased for it though< 'ut itDs all in good fun(

Although youDre allo#ed to cough or sneee as you have a face+ask on< itDs polite to face a#ayfro+ the surgical field #hen doing so< and you +ay still feel a#k#ard or e+'arrassed in theprocess( 7f you unfortunately are sick #ith a dry cough at the ti+e< itDs 'est to have lots ofloenges #ith you for the day( $ne or t#o in the +outh prior to scru''ing in #ill hopefully holdyou over for +ost of the surgery(

7f you ever feel faint or lightheaded during a surgery for #hatever reason< there is no sha+e inad+itting so and asking to leave the surgical field< even if itDs te+porarily to take a 'reath( As+any a surgeon has said< theyDd +uch rather you scru' out and sit do#n than passing out ontheir surgical field @too +uch paper#ork if that happens( -ou can al#ays scru' 'ack in #henyouDre feeling 'etter(




Lastly< should you ever accidentally 'reak sterility< #hether so+eone notices or not< o#n up to it(Step a#ay fro+ the ta'le< ad+it you >ust conta+inated yourself accidentally< and ask if you

could go re?scru' and co+e 'ack in( &o surgeon or nurse #ill ever fault you for 'eing responsi'le#hen it co+es to patient safety @and if they do< youDre still in the right( 7f youDre unsure if you 'roke sterility< ask( 7tDs a 'it of etra ti+e and effort to avoid the possi'le< even if sli+< risk ofserious co+plications fro+ surgical infection( *e o#e it to the patient as part of the +edicalprofessional tea+(


: The CLE8SH74 GU7!E ; Ho# to $perate in Surgery



3777( Helping out @retracting<

cutting< staplingsuturing

Having scru''ed in and standing in position< you +ay 'e asked 'y the surgeon to help out atvarious ti+es( !onDt epect to 'e doing anything +a>or< especially since +ost of the ti+e there isan assist or a resident around( 7n general< students #ill 'e asked to hold retractors at variousti+es throughout the +ain part of the surgery( eep good tension on the retractor so a goodsurgical vie# is +aintained< and donDt #orry a'out pulling too hard since skin and connectivetissues are pretty dura'le as long as the retractor is placed in the right position initially( Also dore+e+'er to change your grip or hand once in a #hile< other#ise your ar+s #ill fatigue Fuickly(

At so+e point in the surgery< usually during the closing process< tied sutures #ill reFuire cutting(HereDs #here you can 'e a hero. $ften nurses #ill pre?e+ptively tap your hand #ith the handles

of the scissors< so take that as your cue to take the scissors and 'e at the ready to cut( $ther#isethe surgeon #ill take the scissors and pass the+ to you< so 'e at the ready either #ay( Suturecutting isnDt rocket science @or 'rain surgery< for the neurologists a+ong you< as long as youDrea#are of so+e guidelines"

)( 7f you ask Jho# longK #hen the surgeon asks you to cut< you +ay get Jas long as it needs to 'eK as an ans#er in return( 7nstead< #atch for so+e su'tle cues carefully< such as the surgeondoing a Fuick tap #ith the needle drivers or forceps on the suture line they #ant cut at thelocation they #ant it snipped(

7n general< internal closing sutures and dissolva'le 'uried sutures should 'e cut short @>ust a'ovethe knot< eternal si+ple interrupted skin sutures should have a'out 6(:c+ left to the ends< andany te+porary suture used to pull or +anipulate structures around should 'e cut AB$3E #herethe cla+pshe+ostats are clipped(

/( *hen you need to cut a suture short >ust a'ove the knot< 'ring the scissors right do#n on topof the knot< then tilt the scissors to angle the 'lades 0:

\

< then snip( This ensures you donDt cut theknot< and thereDs enough tension in the re+aining suture length that the knot #onDt slip( Thistrick #ill generate +ore trust in you 'y your surgeon< even if they donDt co+pli+ent you on itspecifically.

,( &o 'lind cutting( 7f you canDt see the suture notched into your scissors 'lades as you cut< along#ith the tips of your 'lades< you shouldnDt 'e closing those handles( &othing #orse thanaccidentally cutting a structure you didnDt see @especially if itDs a vessel.( Better to read>ust yourhand or 'ody to get a good vie#< and if you still canDt see< +ention it to the surgeon and theyDlldirect you as needed 'ased on their preference @they +ay still say thatDs ok< >ust cutD




0( Along #ith suture cutting< you +ay 'e asked to help as the surgeonresident sutures< usually 'y doing so+ething called running the lineD or follo# +eD( This si+ply refers to the+ #antingyou to hold onto the suture line to hold tension in the previous loopknot as they put in the netloop during continuous running sutures( Gently tug on the suture line so itDs taut< 'ut not pullingecessively on the tissue itself< and once the net loop is in< let go so the suturer can pull it tight(Gra' onto the suture line again once theyDve +ade their pass through and are setting the needle

for the net loop(

:( At so+e point you +ay 'e asked to de+onstrate your kno#ledge on sutures< including types ofstitches< knots< suture sie and +aterial< needle shapes and sies< and relations to tissues( This is#here so+e pre?reading helps @use the super colourful +anual the faculty gave us to learn(

*hen itDs ti+e to close the outer+ost skin layer< you +ay 'e offered the chance to either help#ith the staples or do so+e actual suturing yourself( Using the staple gun is relativelystraightfor#ard( The surgeonresident #ill use t#o pairs of forceps to grasp the skin edges and 'ring the+ together( -ou place the staple gun centred and parallel to the skin surface >ust 'ehind#here the forceps are< and sFueee the trigger to close a staple everting the skin edges( !$&DTlet go of the trigger Fuite yet. Add a little 'it of 'ack#ards traction and #ait until the

surgeonresident re?grasps their forceps onto the net portion of the skin edges( Close anotherstaple in the net location< and repeat as necessary until the entire incision is closed(

7f you get the chance to suture< +ake sure you kno# ho# to do a vertical +attress and a 'uriedstitch< as these are usually the ones used for closure( Also kno# ho# to do ) or /?handed ties< not >ust instru+ent ties. 4ractice< practice< practice until the hand +ove+ents 'eco+e second natureand you understand ho# the knot gets tied #hen you +anipulate and rotate your hands( 7practice 'y using floss on anything you can loop the floss around @e( pencil< and tyingrepeatedly @as a 'onus< you donDt need to unknot the #hole line at the end of the day< since youcan >ust toss the floss(

$n the very< very rare chance you get an opportunity to hold a laparoscope ca+era orinstru+ent< you #ill 'eco+e disoriented #ith the ,?! space< as the hand directions get reversedon the internal side @envision the fulcru+ of the instru+ents at the skin and +uscle tissues( 7fyouDre operating the ca+era< al#ays have the center of the field focussed on the place of action inthe 'ody( Make sure your ca+era vie# is vertical and perpendicular to the horion level< anddefinitely< definitely donDt shiftshakefidget around too +uch< unless you #ant to +ake everyonevie#ing nauseous and diy.


1) The CLE8SH74 GU7!E ; Ho# to $perate in Surgery



7( Cleaning up

$nce the surgery is co+plete< the surgeon #ill usually have already de?go#ned in order to go sortout the operative note and dictation and prepare for the net patient( That #ill leave you and the

assistresident to tidy things up ta'leside< #hich generally involves #iping the incision site clean<applying dressings @e( steristrips and gaue 'andage< re+oving all the drapes and cleaning upeFuip+ent( ThereDll then 'e a 'it of a 'reak #hile the anesthesiologist 'rings the patient out fro+under anesthesia< during #hich ti+e you can chat #ith the resident and have any Fuestions youhad ans#ered( eep in +ind though that theyDll also 'e 'usy #riting the operative note and post?op orders< so see if you can help in any #ay #ith that first 'efore you distract the+ #ithFuestions( -ou should also 'ring in the patient 'ed if it hasnDt already 'een done and 'ring it 'eside the surgical ta'le in preparation for transfer( $nce the patient rouses< put a pair of non?sterile gloves on< and get ready to help roll the patient up on one side< shove the slide ta'le underthe+< and drag the+ onto the patient 'ed( -ouDll 'e told 'y the nurses and anesthesiologist

#here to stand and #hat to do< so follo# their directions( $nce the patient is safely in the 'ed<the patient #ill 'e 'rought to the post?anesthesia care unit( !epending on your resident< you +ayfollo# the+ to the 4ACU #hile the $8 is 'eing cleaned and reset< or you +ay go see the netpatient on the slate to get properly prepared(


1/ The CLE8SH74 GU7!E ; Ho# to $perate in Surgery



( *ash< rinse< and repeat

All in all< thatDs the gist of the surgical day process< and you repeat this until all the surgeries onthe slate are co+plete( 7n 'et#een surgeries< you should also try to find so+e ti+e to check on

the patients post?op in 4ACU to ensure theyDre doing alright and there are no #orriso+e signspresent @e( hypotension< tachycardia< 'leeding through 'andages( Any given surgery day +ayhave any#here fro+ / to 2 patients< depending on the surgical service and thelengthco+pleities of the surgeries(

!efinitely look for any opportunity you have to sit do#n< as your 'ack #ould really appreciate it 'y the +iddle of the day( Also go gra' food Fuickly #hen you can and use the #ashroo+< sinceyou never kno# for sure ho# long the su'seFuent surgery +ay take 'efore you get a 'reak( 7nthis #ay< youDll survive your surgical days( ThereDs plenty +ore to learn and pick up< 'ut thoseco+e fro+ eperience< and you certainly #onDt 'e epected to 'e rock stars and kno# everything 'eforehand( Ho#ever< hopefully after reading this section< at least thereDs less aniety a'out thepossi'ility of +aking a total fool of oneself in this unforged territory.


1, The CLE8SH74 GU7!E ; Ho# to $perate in Surgery





4rotecting yourself #ith

insurance

Anna AFuino< BCMA Student Advocate< M! /6)0

Congratulations on +aking it to your third year. -ouDre even closer to 'eing the doctor you haveal#ays drea+ed of P you get to treat real patients fro+ no# on. 7tDs sure to 'e an ehilaratingly 'usy year(

Before you i++erse yourself in learning to care for others< take a +o+ent to think of yourself(Co++utes youDll have to take P #hether 'y transit< driving< 'iking< or #ith your o#n t#o feet(The stress youDll undou'tedly feel crushed 'y at so+e point over the net year( The 'ustling<hectic environ+ent of hospital hall#ays< E8s< $8s< and #ards( &ot trying to sound like a !e''ie!o#ner< 'ut you +ay 'e faced #ith +any challenges that knock you do#n health?#ise" a 'roken

'one fro+ an accident< stress so over#hel+ing that you >ust need to take a 'reak fro+ it all< anunepected needle prick( 7f you need to take etended ti+e a#ay fro+ clerkship for your health<#hat happens to your loans and lines of creditI Likely< youDll 'e reFuired to start pay+ents or#orse< you #onDt 'e a'le to dra# out funds(

!isa'ility insurance< to the rescue. 7f youDre not a'le to attend clerkship or school for over 6days due to an accident< illness< in>ury< or even stress< you could 'e eligi'le to receive disa'ilityinsurance 'enefits( !isa'ility insurance provides +onthly ta?free pay+ents to help you coveryour living< schooling and +edical costs until you get 'ack on your feet( 8ecovering fro+ illnessor a stress episode is not the ti+e to 'e #orrying a'out ho# youDll pay your 'ills( The BCMA

offers an afforda'le plan to students @N/<:66 of +onthly coverage for only N)/: per year if youDreunder 06< and you donDt have to ans#er any Fuestionnaires or have a +edical ea+ done( -oulikely enrolled in the BCMA Student !isa'ility in first year< 'ut if you didnDt rene# your policyyou +ay no longer 'e covered( Check your insurance status 'y calling BCMA at )?266?11:?//1/

or e+ailing BCMA7nsurance'c+a('c(ca ( -ou can also 'ook an appoint+ent #ith oneof BCMADs 7nsurance Advisors #ho #ill gladly +eet #ith you in person< over the phone< or viathe net to discuss your insurance Fuestions and needs( !onDt #orry< theyDre not pushy ? theyDrenon?co++issioned e+ployees of the BCMA #orking for +e+'ers(

8e+e+'er< no# is the ti+e to +ake sure you are protected so you can focus )66 on yourstudies(

1: The CLE8SH74 GU7!E ; *ellness

mailto:[email protected]

mailto:[email protected]



%inding a place to rela

There #ill 'e +o+ents @perhaps too +any of the+ #hen youDre feeling over#hel+ed< 'urnedout< and in need of a 'reak( Most hospitals are pretty 'usy and it can 'e difficult to get a#ay fro+

the chaos even for a couple of +inutes< 'ut there are #ays to do it.

Go for a #alk( 7f you can find the ti+e< get outside and 'reathe so+e fresh air.

Sit in the courtyard @if your hospital has one( So+e hospitals< like St( 4aulDs and 8CH<have lovely courtyards that offer a Fuick outdoor escape right on hospital property(

Go to your call roo+( So+eti+es the call roo+s are a 'it far a#ay< so this isnDt al#ayspossi'le< 'ut if you have the ti+e< itDs a good place to shut out the rest of the hospital(

%ind an ecuse to visit a Fuieter area of the hospital( 8adiology and pathology are t#oareas that you +ight 'e a'le to find a reason to visit< and they are usually pretty Fuiet

co+pared to the rest of the hospital.

Go to an upper floor and check out the vie# for a couple of +inutes( Looking out atEnglish Bay @St( 4aulDs< %alse Creek @3GH< or the %raser 8iver @8CH provides a cal+ing 'reak during a 'usy day(

*hen in dou't< go on a #ashroo+ 'reak( &o one can fault you for heeding the call ofnature< and doing so offers a fe# +inutes a#ay fro+ your #ork.


11 The CLE8SH74 GU7!E ; *ellness



Supports availa'le to you

7f youDre starting to feel over#hel+ed 'y everything< try talking to so+eone a'out it to receiveso+e +oral support( Here are a fe# suggestions on #ho to go to #hen you need that etra

encourage+ent"

-$U8 CLASS MA ES

These people kno# #hat youDre going through and can sy+pathie< so donDt 'e afraid to talk toyour peers a'out ho# youDre feeling. Chances are theyDre having si+ilar feelings a'out everythingyou are eperiencing in ,rd year( Talk to each other< vent< share coping strategies< and youDll 'esurprised at ho# Fuickly youDll feel 'etter.

8ES7!E& S

7f you find a resident that you get along #ell #ith< they can 'e an ecellent source of support(TheyDve gone through #hat youDre going through and survived to tell a'out it< so they +ay 'ea'le to offer you so+e advice and +otivation(

S7 E !78EC $8S48$G8AM ASS7S A& S

The people in charge of your site andor rotation are a good option if that over#hel+ed feelingis either related to the epectations of the rotation or is affecting your perfor+ance( 7f youDreupfront a'out ho# youDre doing< youDll 'e +ore likely to get so+e help dealing #ith all thereFuire+ents( 7tDs far 'etter to let people kno# youDre struggling as soon as you run into trou'le

rather than trying to eplain #hen you get a not?so?hot grade or assess+ent.

$%%7CE $% S U!E& A%%A78S

As al#ays< the people at the $SA are here to help and offer support and advice as you navigate+edical school( -ou can speak to the+ confidentially a'out ho# youDre doing and theyDll 'e a'leto help you figure out the 'est #ay to +anage(

A& 7&!E4E&!E& C$U&SEL$8

7f you have health insurance< usually you #ill have enough coverage to go to a'out , sessions#ith a Fualified counselor or psychologist #ithout having to pay for it yourself( Talking toso+eone #ho is co+pletely separate fro+ your +edical school life has its 'enefits and +ay +akea 'ig difference to your sanity. -ou can search for counselors online @+ake sure they areFualified. or ask your fa+ily doctor @or Student Health at UBC for a reco++endation(





Ho# to fit in eercise

*ith long hours at the hospital< long hours of studying< and trying to fit in so+e fa+ily 9 friendti+e< eercise +ight fall to the 'otto+ of your To !oD list( 7f you can< taking ti+e to get to the

gy+< go for a run< or attend a yoga class @yoga and Med%it classes take place #eekly at theMSAC ? #atch your +ed?all e?+ails for details. #ill likely do a lot of good for 'oth your +indand 'ody( But #hat if you donDt have ti+e to do those activities @and you canDt 'ear the thoughtof getting up an hour early to +ake ti+eI -ou can incorporate eercise into your day so that youstay healthy #ithout having to take the ti+e to #ork out( Bike or #alk to #ork if you live closeenough to do so( Take the stairs instead of the elevator @in places like St( 4aulDs< youDll pro'a'lyget to your floor faster any#ays.( 7f there is a gy+ on site or near'y< you could do a Fuick#orkout over your lunch 'reak( Stand #hile you #rite your notes and take a second to stretch(Tense and release your +uscles to keep the+ #orking during rounds( Every little 'it counts.





Biking to the hospitals

@Thank you to Heather Taddy< Lisa Ho#ard 9 &iky Hatfield for the infor+ation

3GH"

A 'ike cage is availa'le in the !ia+ond 4arkade( -ou need your 3GH 7! card to 'e activated 'ysecurity so that you can access the 'ike cage and the ad>oining locker roo+s(

The door to the locker roo+s is located across fro+ the door to the elevators on the first floor ofthe parkade( There are lockers and sho#ers availa'le( There are li+ited lockers so if you are notat 3GH for a #hile please re+ove your lock to leave space for others(

There are also sho#ers availa'le in the $8 change roo+s and the Call 8oo+ area(

Lastly< donDt forget a'out 'ike parking in the MSAC courtyard @access #ith 3GH 7!( Sho#ersand lockers are availa'le in the 'ase+ent( This is the 'est place to park and sho#er #hen headingto BCCA(

S4H"

A 'ike cage is availa'le in the S4H parkade off of Burrard( -ou need a 4rovidence 7! card toaccess it( These cards are availa'le fro+ the 7!security people on the 0th floor of Burrard 'uilding(

Sho#ers are located in locker roo+s of 0th floor of Burrard >ust outside of the eating disorderclinics( There are also sho#ers in the call roo+ area @1th floor Burrard and in the $8 change

roo+s( -ou need your 4rovidence 7! to access all of these(

There are lots of lockers in the ne# call roo+ area ? 'ring your o#n lock(

BCCHBC*H"

A 'ike cage is availa'le in the parkade located under the entrance to la'our and delivery @southside of 'uilding( -ou need a key to access it( -ou can purchase a key for N)6 @theyDll give you N: 'ack if you return it fro+ the cashier office @fro+ Ti+ Hortons #alk do#n the hall#ay to#ardsChildrenDs hospital< office is >ust past the first elevator on the left((

Sho#ers and lockers are located on the second floor of BC*H @right side of hall#ay as you #alkfro+ childrenDs to #o+enDs( MenDs locker roo+ is to the right through glass doors( There are alsosho#ers in the ChildrenDs hospital call roo+ area @'y the cafeteria and the $8 change roo+s(




UBC H$S47 AL"

Bike cage is at the hospital parkade or in the parkade across fro+ the Life Sciences Center @Go tothe UBC trek office for the code( Sho#ers and lockers are in the Life Sciences center and $8change roo+ in the hospital(

8CH"

A 'ike cage is located in the parkade @entrance off eary St(( A key card is provided as part of7! at the start of the rotation< 'ut you have to ask S4EC7%7CALL- for the one that opens the 'ike cageR not all of the cards do this(

Lockers and sho#ers are in the studentresident lounge(

8GH"

The 'ike cage is located on the ground floor of the +ultiple storey parkade( Access is via your3GH 7! that you can have coded fro+ the 4arking and Security $ffice( Ask at the info desk for

directions< 'ut it is farther do#n the sa+e hall#ay used to access the $8 locker roo+s(

7f you are on a surgical rotation< it is +ost convenient to use a visitor locker in the $8 changeroo+< and there is a sho#er there( There are also call roo+s upstairs 'y the #ards #ith sho#ersand lockers(

LGH"

The 'ike cage is located in the corner of the ground level parking lot( To access it turn in thedrive#ay off ):th Street( eys to the 'ike cage are availa'le fro+ the Cashier inside the doorclosest to the 'ike cage for a s+all deposit(

S+all lockers are availa'le near the !octorQs lounge+ail'oes on the +ain floor of the hospital<or in the $8 locker roo+( Sho#ers are availa'le either in the $8 locker roo+< or in the callroo+s in the to#er near the #ards( To#els are provided( The education assistant #ho #ill 'ee+ailing you #ith your rotation infor+ation can sho# you #here the lockerscall roo+setc are(





*here to find good healthy eats

To Fuote a #ise +edical student< J7f you donDt eat< you #onDt think((( thatDs 'ad(K

Maintaining regular and healthy eating ha'its is i+portant as you #ork through cray hours inthe hospitals( Al#ays take ti+e to eat< even if itDs >ust a )6 or ): +inute pause to eat yoursand#ich( Most preceptors and residents are good a'out +aking sure you get 'reaks to eat< 'utdonDt 'e afraid to ask for the ti+e if they havenDt noticed that your sto+ach is gro#ling.

The 'est #ay to 'e sure youDre eating healthy< inepensive food is to pack your o#n( Sand#ichesand salads are Fuick and easy options< 'ut +ost sites give you access to a fridge andor a+icro#ave< so you can get a little +ore creative #ith your food choices as #ell( Try to puttogether your food the night 'efore to save ti+e in the +orning( Having a granolapo#er 'ar orother Fuick snack in your pocket or 'ag is a good idea< too< for those ti+es #hen you +ight not 'e a'le to gra' a proper +eal #hen you start feeling hungry(

7f you need to 'uy food @and< letDs face it< it can 'e tough to pack enough food for those cray /2hour call shifts.< there are usually a fe# options at each hospital(

3GH"

The cafeteria is on the second floor and has a variety of options including sand#iches< chickenfingers< stir fry< and pia( Cafe A+i is also on the +ain floor 'y the )/th Ave entrance< #hich is 'asically a coffee shop that also has various sand#iches< yogurt< and other snacks( 7f you haveti+e to venture outside of the hospital< there is a Ti+ Hortons on Broad#ay< Minato Sushi at

$ak 9 Broad#ay< and a Su'#ay very close to Minato( There are also several Thai< =apanese< and7ndian food restaurants in the area( The 7ndian restaurant at Broad#ay 9 *illo# has N: lunch 'o specials. Star'ucks is in the !ia+ond Centre(

The call roo+ has a fridge and +icro#ave( 7f youDre on your Surgery rotation< there are also giantfridges as #ell as +icro#aves in the $8 lounge( Micro#aves can also 'e found in the cafeteria(

S4H"

St( 4aulDs 'oasts a #ide array of yu++y and Fuick food options in the vicinity< especially if you

have ti+e to #ander over to !avie St( There are Star'ucks locations at !avie 9 Thurlo# or atHo#e 9 Hel+cken( Ti+ Hortons is at !avie 9 Ho#e( There is a cafeteria on the 0th floor of the4rovidence Building< 'ut the selection is li+ited(

The call roo+ has a fridge and +icro#ave that students can use(

5) The CLE8SH74 GU7!E ; *ellness



BCCHBC*H"

-ouDre going to #ant to pack lots of food for #hen youDre at BC ChildrenDs 9 *o+enDs Hospitals 'ecause the food options are sorely lacking( The cafeteria is on the +ain floor on the *o+enDsside @#hich closes at 1p+< and there is an J$n The GoK Ti+ Hortons in the *o+enDs lo''y @'utthey donDt have all the sand#iches and everything that a full Ti++yDs #ould( A Second Cupcoffee shop is located in the ChildrenDs +ain lo''y #ith so+e decent paninis and othersnacks<and they are open the latest of all the food places @)6 or )) p+( Star'ucks is in the

A+'ulatory Building 'ut closes relatively early< so +ake sure youDre ar+ed #ith your o#n snacksand coffee for overnight call shifts. There is a Safe#ay at $ak 9 ings#ay< 'ut thatDs pretty +uchit for food in the area(

There are fridges 9 +icro#aves in the +ini?kitchens on the #ards that you can use< and thereDsalso a +icro#ave in the call roo+(

8CH"

The 'ase+ent houses the not?so?great cafeteria< 'ut there is also a Ti+ Hortons on site(

Star'ucks< Su'#ay< sushi< pia< and a deli are all near'y(

8CH also 'oasts a fa'ulous residentstudent lounge in the 'ase+ent #ith a fridge< +icro#aves<toasters< and even free food @cereal< +ilk< yogurt< 'agels< cheese< fruit 9 >uice are usually instock(

8GH"

The cafeteria is on the /nd floor and there is a Star'ucks right in the hospital( Most other foodoptions are a 'it of a hike outside the hospital ? Mad Greek is a'out a : +inute #alk a#ay< 'uttends to 'e on the epensive side(

There is a lounge shared 'y students 9 staff and in the hall#ay 'y the lounge are a fridge and+icro#ave(

SMH"

-ouDll find the cafeteria on the /nd floor @it has good 'reakfast 9 lunch options< and there is acoffee shop #ith Star'ucks coffee right net to the cafeteria( A Ti+ Hortons is across the street oning George Blvd(

The residentstudent lounge on the ,rd floor is Fuite nice and has a fridge and +icro#ave foryour use(

5/ The CLE8SH74 GU7!E ; *ellness



LGH"

The cafeteria is on the )st floor at LionDs Gate< 'ut the hours are pretty li+ited( There is also acoffee shop in the hospital< 'ut itDs not the greatest< so you +ight #ant to head outside to theStar'ucks< Blen< or Ti+ Hortons #hich are fairly close 'y( There are lots of food options near'yas #ell< including Thai food< sushi< Su'#ay< and &andoDs Chicken(

There are fridges and +icro#aves in the call roo+s< in La'our 9 !elivery< and in the $8 lounge(

UBC H$S47 AL"

The UBC hospital is a s+all one so on?site options are li+ited< 'ut itDs very close to 'oth theStudent Union Building< #here there is a Star'ucks and a s+all food court< as #ell as The3illage< #hich has Fuite a fe# food options(

GH"

elo#naDs hospital has a coffee shop and a cafeteria on the +ain floor( $ther#ise< youDre looking

at a : +inute drive or /6 +inute #alk to find other food options at 4andosy 3illage @includingSu'#ay< a pu'< a coffee shop< and a couple other restaurants(

Unfortunately< thereDs no access to a fridge or +icro#ave at GH(

M7LLS MEM$87AL H$S47 AL"

The cafeteria in the 'ase+ent has okay food( Ti+ Hortons is a )6 +inute #alk a#ay< andeverything else is a'out a : +inute drive( Ankas and !on !iegos are good options(

The student lounge has a s+all kitchen you can use(

3E8&$& =UB7LEE H$S47 AL"

The cafeteria is in the 'ase+ent of the old to#er< 'ut has strange hours @itDs open for 'reakfastand lunch 'ut closes around ),66 and is only open on #eekdays( The food< ho#ever< is decentand the prices are reasona'le( The Crack 4ot Cafe is on the +ain floor of the hospital @open6166?)66 and a little pricier than the cafeteria< 'ut there is a Star'ucks as #ell as #raps< a /0?hour Su'#ay< and an Earls at the 'otto+ of the hospital hill @a'out :66 + fro+ the hospital( 7fyou #alk another 0?: 'locks further north into do#nto#n youDll find 7ndian< Asian< Greek< andother Mediterranean food(

There is a staff lounge on the ,rd flood of the ne# to#er #here youDll find a fridge< +icro#ave<and free cookies 9 coffee.

5, The CLE8SH74 GU7!E ; *ellness



CH7LL7*AC"

The cafeteria is on the +ain floor< Star'ucks is / 'locks a#ay< and +ultiple restaurants are #ithina )6 +inute #alk of the hospital(

The doctorDs lounge is shared #ith students and has a +icro#ave(

487&CE GE$8GE 8EG7$&AL H$S47 AL"

The cafeteria is in the 'ase+ent and includes a Ti+ Hortons( Second Cup is a : +inute #alka#ay< as are 4ita 4it< Ouinos< Booster =uice< 4ia Hut< a Chinese 8estaurant< a 3ietna+eserestaurant and a s+all soupsand#ich place(

The student lounge on the :th floor has a fridge and +icro#ave(





General #ellness tips

Talk to your peers ? they understand #hat youDre going through and can 'e a huge sourceof support(

Make your health a priority( Make sure you eat proper +eals and get a decent a+ount ofsleep on your non?call nights( Studying is i+portant< 'ut it #onDt 'e overly effective if youcanDt think straight 'ecause youDre tired or hungry.

Try to +ake ti+e for friends and fa+ily< as #ell as for an activity that you en>oy that isnDtrelated to +edicine( 7tDs i+portant to +aintain a 'it of 'alance< even though ,rd year tendsto 'e #eighted heavily on the +edicine side of life( !onDt #ait until youDre co+pletelyover#hel+ed to ask for help( As soon as you realie youDre struggling a 'it< find so+eone totalk to a'out it.


5: The CLE8SH74 GU7!E ; *ellness



S7 ES" 3%M4

BCCHBC*H" BC ChildrenQs 9 *o+enQs Hospital(( ( ( ( ( ( ( ( ( ( ( ( (55

LGH" Lions Gate Hospital(( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 2)

MS=H" Mount Saint =oseph Hospital(( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( (20

4AH" 4eace Arch Hospital(( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 2:

8CH" 8oyal Colu+'ian Hospital((((((((((((((((((((((((((((((((((((((((21

8GH" 8ich+ond General Hospital(( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 2

SMH" Surrey Me+orial Hospital(( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( /

S4H" St( 4aul Qs Hospital(( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( :

3GH" 3ancouver General Hospital(( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 2

51 The CLE8SH74 GU7!E ; Sites" 3%M4



BCCHBC*H" BC ChildrenQs

HospitalBC *o+enQs Hospital

*ritten 'y Erica Chhoa< M! /6)0 and Aaron Gropper< M! /6),Edited 'y Erica Chhoa and =ackson Chu< M! /6)0

BC ChildrenDs Hospital and BC *o+enDs Hospital are 'oth located on the sa+e site in central3ancouver( Although ulti+ately serving different populations< BCCH and BC*H are si+ilar inthat provide very specialied care and are therefore ideal places to see pediatric and o'stetriccases respectively(

BCCH is the pri+ary childrenDs hospital in British Colu+'ia and therefore is not only the 'usiestpediatric care center< 'ut also the site +ost likely to provide you #ith the greatest 'readth ofpediatric eposure( Because of its high volu+e< ho#ever< students are kept significantly 'usier

and #ork longer hours than at other pediatric sites( BCCH offers an unparalleled eperience forstudents interested in pediatrics 'ut possi'ly an over#hel+ing one for students that rankpediatrics lo# on their Ca8MS list(

The large +a>ority of patients that co+e to BC*H are peripartu+( BC*H offers care to fa+ilies 'efore< during and after pregnancy in addition to providing specialied treat+ent for high riskpregnancies and infertile couples( 7f you choose to do the o'stetric portion of your $'sGynerotation at BC*H @the Gyne portion is held at 3GH you *7LL help deliver at least one 'a'yon +ost call shifts( Because there is al#ays a +other in need of care of BC*H< epect to getlittle sleep during call shifts( This is in contrast to other $'sGyne sites( Ho#ever< if you

$'sGyne is your thing< you are strongly encouraged to co+plete the rotation at 3GHBC*H(

GE 7&G HE8E

By car< BCCHBC*H is a'out )6 +inutes fro+ 3GH( Both Ca+'ie and $ak St #ill take youthere in no ti+e( 4arking is availa'le on site at a staff rate of N1(5:day( -ou can also park forfree in the surrounding area< although +uch of it is Yresidents onlyY or a /?hour li+it( There isso+e non?restricted parking on the 'lock north#est of ing Ed#ard and $ak St @on /,rdavenue< or any of the streets #est of $ak St( %ro+ these off?site parking spots< 7t is a )6 +inute#alk to BC*H((( or if you are really lae you can try to catch the V/:(

7f you decide to eercise your flashy UBC 'us pass< the V)5 #ill pick you up fro+ the ChildrenQsHospital entrance and drop you off at the V or the skytrain station( Although it runs all the#ay do#nto#n< it is not the +ost relia'le line so leave plenty of ti+e( A second line is the V/:#hich runs along ing Ed#ard( The stop is a less than )6 +inute #alk to the hospital(Alternatively< you can take any 'us along ing Ed#ard Avenue or $ak St(




Co++uting fro+ 3GH or S4H is a 'reee and there is a shuttle that runs 'et#een these sites andBCCHBC*H( The shuttles run every half hour and stop is at the entrance closest toC%87CMMT( The schedule can 'e found here"http"###(phsa(ca&8rdonlyres/CA6)!A?%!C6?0B)?::%? /C21)5%%5)2B6ShuttleSchedule(doc

S $87&G -$U8 S U%%

B C C H

4ay attention during orientation as you #ill 'e sho#n #here the lockers are. 7f you +iss theannounce+ent< the lockers are on the /nd floor(

B C * H

There are a fe# lockers availa'le in the change roo+ ad>acent to the $8 'ut there are rarely anye+pty lockers( -our 'est 'et is to coy up to the nurses and use their space( Each #ard< includingthe ad+ission area< has a secure nursesD lounge( $ften there is an e+pty cu''y there to put your

'elongings(

EE47&G CLEA&

B C C H

-ouDll find sho#ers in the call roo+ area< and there are to#els in the 'ack corner if you +akeyour #ay around the circle of call roo+s(

B C * H

7n addition to there 'eing lockers @and to#els and scru's in the change roo+ 'y the $8< there isalso a sho#er( Although at first glance the sho#er looks Fuite 'asic< >ust a sho#er head< a tilefloor and a curtain< it 'eco+es divine after a long night of deliveries(((or one +essy delivery.

CALL 8$$MS

B C C H

The call roo+s are in the +edical student lounge< #hich is close to the cafeteria( Get so+eone tosho# you #here it is< 'ecause itDs a difficult location to eplain. There are Fuite a fe# call roo+s<so+e of #hich are designated for a certain service @donDt use so+eone elseDs call roo+ or theyDllend up sleeping on the couch.(

B C * H

There are t#o call roo+s located on the second floor( The roo+s are very 'asic #ith a desk and a 'ed( The resident that you are on call #ith should have the access code( *hen on call< the roo+sare a great place to store your 'elongings 'ut donDt count on +uch sleep.


http://www.phsa.ca/NR/rdonlyres/92CA01DA-FDC0-49B1-955F-2C8617FF718B/0/ShuttleSchedule.doc






HE L$U&GE

B C C H

There is a lounge and kitchen area #here the call roo+s are( ThereDs also a ne# residents loungeover 'y the #alk#ay to the a+'ulatory 'uilding that is al#ays stocked #ith snacks((( 'ut +edicalstudents donDt have access to it< so youDll have to 'efriend the residents in order to get in.

B C * H

There is a residentDs lounge located on the +ain floor of BC*H( The access code #ill 'eprovided during orientation( This lounge is #here +orning rounds are held( The a+enities arepretty 'asic and include couches and a T3( %ridges and +icro#aves can 'e found in the +ultiplenursesD lounges(

HE CA%E E87A

The cafeteria is found on the ground floor of the hospital( 7t has a good variety of food and +anystudents rely on it daily( Sand#iches< salads< 'urgers< pia< a daily special a+ong other ite+s are#hat you can epect( Be sure to check the hours ho#ever so that you do not find it closed #hen

you are on call.

C$%%EE.

There is a Ti+ Hortons< Star'ucks< and a Second Cup all on site so you should never 'e #ithoutcaffeine. *hile the Star'ucks and Second Cup are located in BCCH< the Ti+ Hortons is found inBC*H( The Second Cup is open the latest(

G$$! EA S CL$SE B-

All of the coffee places #ill sell s+all treats in addition to sand#iches and other s+all +eals( 7fyou prefer to venture off site< there are restaurants< a sushi place< and Safe#ay at ing Ed#ardand $ak St #hich is only a :?+inute #alk fro+ the hospital(

HE L7B8A 8-

The li'rary is on the second floor of BCCH and has +any cu'icles< chairs< ta'les for studying(There is also a good shelf of reference +aterials and tet'ooks(

C$M4U E8S

There are co+puters in the BCCH student lounge and in the li'rary(




$3E8ALL 7M48ESS 7$&

Located centrally< co++uting to BCCHBC*H is no +ore cu+'erso+e that traveling to 3GH(4arking is cheaper too. *hile BC*H is s+all and easy to navigate< BCCH is large and oftentakes so+e ti+e to 'eco+e fa+iliar #ith( Both sites are 'usy< providing a+ple opportunity forpatient interaction< learning and hands?on eperience( The staff and residents at 'oth sites arekno#ledgea'le< freindly and ecited to teach the keen student( Ho#ever< they also have higherepectations and are +ore de+anding than at other sites(





LGH" Lions Gate Hospital

*ritten 'y Leslie Anderson< M! /6),Edited 'y Erica Chhoa< M! /6)0

LionDs Gate Hospital is a co++unity hospital serving the uniFue and diverse population of &orth3ancouver( This co+es #ith 'oth advantages and disadvantages( The +ain disadvantage is thatthe 'readth of eposure is li+ited( %or specialties like paediatrics and o'sgyne< this +eans a lessde+anding schedule 'ut +ore self study reFuired( The advantage of #orking at LGH is the directcontact #ith staff physicians( -ou can epect to play a +uch larger role in the care of patientsand surgical procedures(

GE 7&G HE8E

LGH is a little out of the #ay for +ost 'ut this does not necessarily +ean that you need a car( 7fyou are driving< you can epect the trip to take a'out /: +inutes #ithout traffic fro+ 3GH( Aslong as traffic is Fuiet< the 'est route is over the LionDs Gate Bridge and then east along Marine!riveeith 8oad( High#ay ) is an alternative option and the travel ti+e is very si+ilar(

The LGH parking lot is accessi'le fro+ E( ):th Street off of St( GeorgeDs Avenue( The staff rate isN:(5:day( A te+porary parking pass is reFuired to get this rate and the pass is o'taina'le fro+the Cashier on the +ain floor 'y Ad+itting( 4arking #ithin a four 'lock radius of the hospitalhas a t#o hour ti+e restriction 'ut there is free parking a'out : 'locks fro+ the hospital @past)2th Ave( There is also a free parking lot at the corner of Moody( 7tDs a'out a 5?+inute #alk tothe hospital(

Using the #onderful 3ancouver pu'lic transit syste+< you #ill have to first find your #ay to&orth 3ancouver using either the SeaBus or a 'us that crosses the 'ridge( $nce you are in &orth3ancouver< the V/,6 and V// 'uses 'oth stop at Lonsdale 9 ),th< #hich is a 'lock #est of thehospital( %ro+ 3GH< an alternative is to travel to *est Georgia do#nto#n and transfer to theV/06 fro+ there< #hich #ill drop you off at the ): th street entrance to the hospital( The trip isa'out an hour long(

7 have great ad+iration for any student that #akes up etra early and is prepared to get ho+e alittle late< and +ay'e a little #et< 'ecause he or she uses a 'ike for transportation( 7f you are oneof these students< your 'ike #ill 'e #ell taken care of at LGH( The 'ike cage is located in the

corner of the ground level parking lot( To access it< turn in the drive#ay off ):th Street( eys tothe 'ike cage are availa'le fro+ the Cashier inside the door closest to the 'ike cage for a s+alldeposit( -ouDll find plenty of hills along the #ay so ride is especially re#arding @and grueling(

2) The CLE8SH74 GU7!E ; Sites" 3%M4



S $87&G -$U8 S U%%

Lockers are availa'le and you can reFuest one 'y sending a polite +essage to the person #hosends you your site infor+ation @currently Michelle Snyder if you are not auto+atically assignedone( The +ain lockers are located in the doctorDs lounge on the first floor 'ut there are alsolockers near La'our 9 !elivery if youDre on your $'sGyne rotation( Although there are lockersin the $8< there are rarely any free ones(

EE47&G CLEA&

-ou #ill 'e a'le to find sho#ers ad>acent to the call roo+s and in the locker roo+s( To#els areprovided( Although it +ay see+ silly no#< nothing +akes you feel +ore hu+an at ,a+ then anice sho#er(

CALL 8$$MS

The +ain call roo+s are on the 0th floor of the +ain to#er( !epending on your rotation< you+ay 'e given access to other call roo+s(

HE L$U&GE

%ound in the 0th floor on?call area< it has 'oth a fridge and +icro#ave( 7f you are at LGH onyour $'sGyne rotation< the la'our and delivery nursesQ area is also availa'le for your use( Thisarea also has a fridge and a +icro#ave( 7n addition to the studentDs and nurseDs there is also adoctorDs lounge on the /nd floor( -ou #ill 'e given the access code during orientation(

HE CA%E E87A

The cafeteria is located near the +ain hospital entrance on the first floor( 7t has li+ited hours so+ake sure to 'ring food #ith you #hen youDre on call(

C$%%EE.

There is a coffee shop in the lo''y of the hospital( Ho#ever< it has 'een given very poor revie#s(*ithin a fe# 'locks of the hospital on Lonsdale< youDll find a Star'ucks< Blen and Ti+ Hortons(

G$$! EA S CL$SE B-

Lonsdale is your 'est 'et to find a nice fresh +eal outside of the hospital( Along this street there

are plenty of options on Lonsdale including rua Thai< Sushi< Su'#ay< Ti+ Hortons< &andosand Safe#ay(

2/ The CLE8SH74 GU7!E ; Sites" 3%M4



HE L7B8A8- 9 C$M4U E8S

There is a li'rary on the first floor of the hospital near the video conference area( 7t is openMonday to %riday< fro+ 6266?)166 hours( /0?hour access is availa'le through the !octorDsLounge( 7n addition to co+puters< there is also UBC secure #ifi availa'le(


2, The CLE8SH74 GU7!E ; Sites" 3%M4



MS=H" Mount Saint =oseph

Hospital

*ritten 'y Sa'rina Eliason< M! /6),

GE 7&G HE8E

Located >ust t#o 'locks north of the &o( or &o( 'us stop on ings#ay and Broad#ay(

S $87&G -$U8 S U%%

There is no allocated area for +edical students to store their 'elongings other than on the#ardin the depart+ent @i(e( E8 they are #orking(

EE47&G CLEA&CALL 8$$MSL$U&GE

&o Call roo+s(

HE CA%E E87A

A s+all cafeteria #ith li+ited selection of sand#iches< snacks and a daily hot entree(

C$%%EE.

There is a s+all cafeteria on the +ain floor of the hospital

L7B8A8-

&one(

C$M4U E8S

&one that are allocated for personal study(





4AH" 4eace Arch Hospital

*ritten 'y Anne?Marie Madden< M! /6)/

GE 7&G HE8E

Unfortunately< if you live in 3ancouver< you are going to have to drive to *hite 8ock( 7t took +e 'et#een 16?6 +inutes to drive< depending on the traffic( The 'us takes a'out / hours each #ay( 7#as given a free parking pass for the +onth on +y first day( -ou have to use the s+all parking lotacross fro+ the E+ergency 8oo+ entrance( Be sure to give it 'ack at the end of the rotation(

S $87&G -$U8 S U%%

7 left +y stuff in the staff roo+ near the E8 entrance(

L$U&GE

There is a fridge< kettle< and +icro#ave in the staff roo+(

CALL 8$$MS

The only rotation 7 did at 4each Arch #as E+ergency Medicine< so there #asnDt any call(

HE CA%E E87A

There is a Ti+ Hortons on the +ain floor( 7 never checked out the cafeteria(


2: The CLE8SH74 GU7!E ; Sites" 3%M4





S $87&G -$U8 S U%%

4art of the five star eperience at Hotel Colu+'ian is your o#n full sie locker during eachrotation( Lockers are located net to the residentsQ lounge in the 'ase+ent( 7f you forget yourlock< you can 'orro# one fro+ ad+inistration(

EE47&G CLEA&

Sho#ers are also located net to the residentsQ lounge( To#els are provided< although at this pointit is unclear ho# +any students< if any< actually 'other to take a sho#er(

CALL 8$$MS

The call roo+s are located net to the lockers and the residentsQ lounge @all located net to the+edical education office in the 'ase+ent of 8CH( They are Fuite nice< #ith co+forta'le 'edsand pleasant lighting @hence the na+e Hotel Colu+'ian( -ou can also gra' etra 'lankets fro+the hall#ay if you need to @that is< if youQre lucky enough to get so+e sleep.(

HE L$U&GE

The residentsQ lounge at 8CH is the highlight of the hospital< and it #ill undou'tedly enhanceyour eperience in any rotation. There are co+puters< phones< couches< T3< video ga+es< afoos'all ta'le< and a nice vie# of the %raser 8iver( The 'est part is that three ti+es a #eek< theco++unal fridge is stocked #ith goodies like 'agels< cheese< crea+ cheese< ice crea+< cinna+on 'uns< +ilk and fruit >uice( And the cup'oards store cereal< 'iscuits< peanut 'utter and >a+( Thereis also a sink< +icro#ave< kettle< another fridge for your o#n personal food< and a sand#ichgriller. The griller is #ell seasoned @rarely if ever #iped do#n resulting in a grilled cheese #ith aflavour uniFue to 8CH" The 8CH Grilled Cheese Special( !elicious(

HE CA%E E87A

The cafeteria is also located in the 'ase+ent( The food is decent and +oderately healthy 'ut theselection is +ini+al( Most students reco++end 'ringing a lunch or 'uying so+ething off?site"Su'#ay< Ouinos< sushi< and pia are all near'y( Also< donQt 'e afraid to snack on the co++unalfood in the residentsQ lounge. Another i+portant tip is to learn #hen free lunch is offered( %orea+ple< during your 7nternal Medicine rotation< there are usually at least three if not +ore daysa #eek #here lunch is provided @and itQs usually tasty(

C$%%EE.

ThereQs a Ti+ HortonQs in the hospital lo''y< #hich is fantastic]ecept #hen its 'eing used asoverflo# for e+erg( 7f you insist on a J'aristaK +aking your Fuad grande non?fat etra foa+etra cara+el cara+el +acchiato< Star'ucks is north on Colu+'ia( Before +orning report on the7nternal Medicine rotation< coffee is offered free @'ecause you *7LL 'e Jpi+pedK if you fallasleep.




G$$! EA S CL$SE B-

Su'#ay< Ouinos< sushi< salads< and pia are all near'y( ThereQs also a good Thai restaurantdo#n the street that your Attending +ight take you to @or order take?out fro+ if youQre lucky(So+e students also take advantage of a near'y super+arket(

HE L7B8A 8-

The li'rary is ad>acent to the residentsQ lounge and has plenty of co+puters and study space( 7talso has useful tet'ooks that you can 'orro# for a couple of #eeks(

C$M4U E8S

7n addition to the co+puters in the li'rary< there are three co+puters in the residentsQ lounge(

$3E8ALL 7M48ESS 7$&

Although pro'a'ly not right around the corner fro+ your ho+e< the co++ute to 8CH is not a

+a>or 'urden( Many students even ride their 'ike to the hospital fro+ do#nto#n 3ancouverregularly( Beco+ing fa+iliar #ith the hospital is also not a challenge due to its sie and si+plelayout( There are generally fe#er students per rotation at 8CH than at the larger sites resulting in+ore one?on?one ti+e #ith your residents and attending( The student a+enities< includingco+forta'le call roo+s and free food send a clear +essage that 8CH is #elco+ing to< andsupportive of< its students and residents( %or this reason< the at+osphere at 8CH tends to 'e +orerelaed( 8esidents are +ore at ease and staff are +ore #illing to take the ti+e to teach(8egardless of #hich rotation you co+plete at 8CH< you #ill likely have a very positiveeperience(





8GH" 8ich+ond General

Hospital

*ritten 'y =essica %ong< M! /6),

Edited 'y =ackson Chu< M! /6)0

8ich+ond General Hospital is a s+aller co++unity hospital #hich gives it 'oth advantages anddisadvantages( $ne of the +a>or advantages of #orking at 8GH is the direct contact #ith staffphysicians( %or specialties like surgery and o'sgyne< this +eans direct access to the patient asopposed to peering over the shoulder of residents and fello#s( Another advantage is that there arefe#er +edical students in each rotation( 7n the e+ergency rotation< there is only one student. 7fyou are lucky enough to 'e that student< you #ill al#ays have priority access to #ounds that needsuturing< code 'lues and other 'read and 'utter cases( Because of the one?on?one ti+e #ith staffand the increased responsi'ilities at 8GH< this is a great hospital to eperience a specialty that

you are interested in pursuing( &ot only do you get a chance to learn and sho# off your stuff< 'utthe possi'ility of a great reference letter is +uch 'etter here than at other hospitals. $f course<this also +eans that there is no chance to hide in the shado#s so #hen doing a rotation at 8GH< 'e sure to 'e on your ga+e.

GE 7&G HE8E

8ich+ond Hospital is located at the intersection of Gil'ert 8d and *est+inster H#y( 7t isaccessi'le 'y pu'lic transit or 'y car(

7f you are driving to 8GH< head south on Granville and over the Arthur Lange Bridge( $fcourse< there are +ultiple other routes to the Arthur Lange Bridge too. %ro+ the 'ridge< take 8ussBaker *ay &o( / 8oad to#ards 8ich+ond and hang a left on Gil'ert 8oad( The hospital is onGil'ert 8oad >ust past *est+inster High#ay @on the left.( %ro+ 3GH< epect the trip to takea'out ,6 +inutes #ithout traffic( *hen you arrive at 8GH< there is generally plenty of parkingavaila'le in a +ulti?level parkade( *ith a staff parking pass< #hich can 'e o'tained fro+ the sitead+inistrator< students can park for N1(:6day( Monthly parking passes are availa'le 'ut there isno staff rate for these passes( An alternative to parking in the hospital lot is non?restricted parkingon Aure 8oad< approi+ately :?5 +inutes fro+ the hospital(

&o carI 7f you can find your #ay to a Canada Line station< taking transit to 8GH is easy( Si+plytake the Canada Line to the 8ich+ond?Brighouse station( %ro+ there< you can either #alk @a'out)(/ k+ or ): +in or take a short 'us ride @: +in via the V06)?$ne 8oad or V065?Gil'ertdirectly to the hospital(

Cycling to 8GHI There is a 'ike cage is located on the ground floor of the +ultiple storeyparkade( -ou can access the parkade using a 3GH 7! specially coded 'y the 4arking andSecurity $ffice( CanDt find the officeI Head do#n the sa+e hall#ay used to access the $8 lockerroo+s( 7t is past the lockers( $r< 'etter yet< ask at the info desk.




S $87&G -$U8 S U%%

Lockers can 'e found ad>acent to the call roo+s and on 0&( Students on surgical rotations canuse lockers located in the $8 and those on their E8 rotation #ill 'e provided #ith a locker ine+erg( 8egardless of #hich locker you occupy< 'ring your o#n lock.

EE47&G CLEA&

$ne thing that all patients that present to e+erg have in co++on is that they donDt sho#erfirst(((resulting in so+e very interesting odours( There is no ecuse for you to forgo sho#eringho#ever as there are plenty of sho#ers availa'le( They can 'e found 'y the call roo+s in the8otunda @'eside the gy+ or on 0&(

CALL 8$$MS

There are , call roo+s in the 8otunda and , +ore on 0&( To access the roo+s< all that you needis your 3CH 7! 'adge( Students generally prefer the roo+s located on 0&( 7t is fairly easy to get aroo+ as it is really only the surgery and $'sGyne +edical students #ho intend to use

the+(((and only the $'sGyne students that do use the+.

HE L$U&GE

7f you have the luury of getting a 'reak< there is a doctorDs lounge located 'eside the li'rary anda separate lounge in e+erg for E8 docs< nurses and students( Co+puters and a printer areavaila'le for your use in the doctorDs lounge( Both spaces have access to their o#n +icro#ave andfridge(

HE CA%E E87A

HungryI !onDt raid the E8 fridge ? that food is for patients. The cafeteria is located on the secondfloor( Serving hours for hot +eals are fairly li+ited 'ut there are sand#iches and snacks availa'leall day( The hours of operation are 'et#een 5"66a+ to 1",6p+< 5 days a #eek(

C$%%EE.

Coffee can 'e found in the cafeteria on the second floor or at the Star'ucks located in the +ainlo''y( 73 caffeine is not yet availa'le at this site( Star'ucks is open fro+ 5"66a+ to 1"66p+ on#eekdays and fro+ )6"66a+ to 1"66p+ on #eekends(

G$$! EA S CL$SE B-

8ich+ond Centre< a short distance 'y foot fro+ the hospital has #ide variety of options in itsfood court in addition to a grocery store( 7f fast food isnDt your thing< there are also a variety ofrestaurants along *est+inster H#y located #ithin #alking distance fro+ the hospital(




HE L7B8A 8-

The li'rary can 'e found on the +ain floor( 7f you need to access the li'rary after hours< headaround the 'ack through the corridor #here the doctorDs lounge is located @#ith 7! 'adge foraccess(

C$M4U E8S

Co+puters are availa'le in the li'rary 'ut reFuire a login< #hich #ill 'e arranged for you 'y thesite ad+inistrator( The co+puters in the doctorDs lounge do not reFuire a login( There is also #ifi@u'csecure availa'le in +ost parts of the 'uilding(

$3E8ALL 7M48ESS 7$&

Being a s+aller hospital< 8GH is not only easier to navigate than the larger hospitals 'ut is alsoeasier to get to kno# the other health care providers that #ork #ith and around you( Theco++ute is very reasona'le and shouldnDt detract fro+ your eperience at 8GH( Because of itssie< ho#ever< the patient volu+e is reduced and you +ay not see as +any cases as you +ight at

3GH or S4H( This is especially true for $'sGyne #here deliveries occur +uch less freFuentlythan at BC*H( 7n addition< 8GH is not a trau+a center #hich li+its your eperience in 'othsurgical specialties and e+ergency( Altogether< ho#ever< the hands?on eperience that you #ill getat 8GH is unparalleled 'y the eperiences at larger hospitals and you #ill find the ti+e that youspend there very re#arding(


) The CLE8SH74 GU7!E ; Sites" 3%M4



SMH" Surrey Me+orial Hospital

*ritten 'y Andy Chen< M! /6),Edited 'y La#rence Haiducu< M! /6)0

Surrey Me+orial Hospital is a 'usy tertiary care center that is part of the %raser Health Authorityservice area( 7t sees a #ide variety of pathologies< and its average patient population is youngerthan other hospital sites( Coupled #ith the fact that SMH has the /nd highest nu+'er ofdeliveries in the province @after BC *o+enDs< this +eans that itDs a great site to eperiencepediatrics( This is especially true for students #ho #ish to see the 'read and 'utter of pediatrics<or #ho are +ore fa+ily practice inclined< and donDt feel eperiencing rare pediatric diseases is anessential part of their learning( Surrey Me+orial Hospital is an availa'le site option for"?pediatrics ? psychiatry P e+ergency(

GE 7&G HE8E

SMH is located in central Surrey at the intersection of ing George Boulevard and 1th avenue(7t is easily accessi'le 'y pu'lic transit< as it is only a )6?+inute #alk south fro+ ing GeorgeSkytrain Station( -es< one C$UL! catch a 'us fro+ the skytrain to the hospital< 'ut that actuallytakes longer than the #alk< and #ould only reflect lainess( 7n ter+s of driving to the hospital< itis 'est accessed fro+ +ost of Greater 3ancouver @ecept 8ich+ond and &e# *est+inster 'yfollo#ing the Trans?Canada high#ay over the 4ort Mann Bridge< taking eit 02 at ):/nd Street<and proceeding south 'efore +aking a right at 1th Avenue(

4A87&G

4arking options include"

N:)(66+onth for a staff parking pass in the +ain parkade for daily drivers

N:(5:day #ith a free staff parking hanger for inter+ittent drivers

%ree residential parking around the area< so+e for residentsD only< others #ith a / hour+a< for very 'roke @or cheapthrifty drivers

SMH Map can 'e found here"http"###(fraserhealth(ca+ediaSMHMap!irectory(pdf

S $87&G -$U8 S U%%

Students can take any availa'le locker 'y the call roo+ area on the /nd floor of Area % @orangeline( These co+e in full or half height< +etal or #ood< and clean or not?so clean( Choose #isely(Beyond this area< the only other place to store stuff #ould 'e your car< or under the nursingstation ta'les of the #ard youDre on @nurses +ay not al#ays like this< so definitely ask 'eforehand.

/ The CLE8SH74 GU7!E ; Sites" 3%M4

http://www.fraserhealth.ca/media/SMHMapDirectory.pdf

http://www.fraserhealth.ca/media/SMHMapDirectory.pdf



EE47&G CLEA&

There are 'rand ne# sho#ers 'y the call roo+s @logical enough( There are to#els 'y thesho#ers( There is a laundry 'in 'y the to#els( U+(((that is all(

CALL 8$$MS

As noted a'ove< call roo+s are on the /nd floor of Area % @orange line( There #ill 'e a

designated call roo+ for +edical students< and #ithin it thereDs a single?sied 'ed #ith a +e+oryfoa+ +attress. Argua'ly the co+fiest call roo+ 'ed encountered a+ong the +a>or hospitals(Beyond that though< there is little else in the roo+ other than a 'edside ta'le( The roo+s can getcold during #inters< so itDs 'est to turn on the old radiator in the roo+ a 'it for heat( 7n the+orning< donDt forget to hang the foa+ doorhanger that says J4lease clean roo+K on the outsidehandle of the door. $ther#ise #hoeverDs on call after you #ill have to change their o#nsheets(((not fun(

HE L$U&GE

Like everything else< the lounge is also located 'y the call roo+s on Area % /nd floor( Thislounge< although s+all< is 'rand ne#< very coy< and has / co+fy couches< a ne# 06X inch #all?+ounted flat screen tv< a co+puter< a s+all dining ta'le< +icro#ave< fridge< eating utensils< andhot chocolatecoffee in the cup'oards. Much of oneDs do#nti+e #hen on call can 'e spent hereeating< #atching tv< and using the co+puter at the sa+e ti+e( As SMH only has a fe# +edicalstudents and residents around< +ost of the ti+e the lounge #ill 'e free for >ust the on?call studentto en>oy.

HE CA%E E87A

The cafeteria is located in the corner of Area B @orange line( Standard hospital fare< 'ut atrelatively reasona'le prices( The cafeteria< like +any others in hospitals< are al#ays closed earlierthan youDd think #ould +ake sense or 'e reasona'le< 'ut thereDs al#ays the vending +achinesaround( The cafeteria actually has so+e prepackaged +icro#ava'le +eals< such as tv dinners and 'urritos< along #ith a good selection of snacks< drinks< and ice crea+ in their vending +achines(This helps #hen itDs late night on call to still find so+ething decent to +icro#ave in the loungeand eat.

C$%%EE.

$nsite caffeine includes the id Cafe @+ain lo''y< south 'uilding< a coffee stop @+ain lo''y<

north 'uilding< and the coffee +achine in the lounge( $ffsite coffee is availa'le at the Ti+HortonDs across the street @at the corner of ing George Boulevard and 1th Avenue(Unfortunately the nearest Star'ucks is a )6X +inute #alk a#ay(

, The CLE8SH74 GU7!E ; Sites" 3%M4



G$$! EA S CL$SE B-

7n addition to the Ti+ HortonDs< there is also a !airy Oueen Brasserie further do#n ing GeorgeBoulevard @#hich has 'urgers and hot food< al'eit at a +arked up price vs other locations(&ear'y restaurant fare includes a night and !ay and S#iss Chalet heading to#ards the skytrainstation< and even closer< the China 3illage *onton House @Fuestiona'le Fuality of food as ital#ays looks co+pletely e+pty(((

HE L7B8A8- 9 C$M4U E8S

Surprise surprise< the li'rary is located #here else 'ut 'y the call roo+s on /nd floor Area %@orange line< rounding out the central hu' of anything and everything that the +ed studentcould need in one place( !onDt have high epectations of this li'rary< as itDs not very siea'le< 'utdoes have / co+puters for use< an all?you?can?use printer< so+e ta'les to read at< and a s+atteringof various 'ooks and references( $ther than these co+puters< the only other choices are theco+puters on the #ards or the one in the lounge( Though s+all< the li'rary does provide a Fuietstudy space as fe# people use it( An alternative study space is the videoconference roo+ do#nthe hall< #hich has +ore co+fy chairs and 'etter air conditioning @other areas of that floor can

get stuffy(

$3E8ALL 7M48ESS 7$&

Surrey Me+orial Hospital is 'y no +eans a hu+ongous hospital< 'ut it is precisely this fact that+akes it a likea'le site to 'e at( Everything in the hospital is #ithin : +inutes #alking distance<#hich is a huge 'oon #hen it co+es ti+e to rush to the delivery suites in the +iddle of the nightduring pediatrics call( 7t also +eans #ithin the first day of #alking around< you #onDt ever 'e lostagain( Also< as there are essentially only / floors that are relevant in any given area of thehospital< it +eans one doesnDt have to #ait forever for elevators that never co+e or #hich are >a+

packed #ith people( The call roo+s and lounge are essentially 'rand ne#< very co+fy and #ellfur'ished< and further i+prove+ents are still continuing to 'e +ade to those spaces( 7t is very+uch accessi'le 'y pu'lic transit< and also has very cheap +onthly parking availa'le< +aking anyfor+ of co++uting si+ple enough< even if so+e find it a 'it far(

The pediatrics eperience is very co++enda'le here< and the #ard and staff are 'oth very#elco+ing and nice( E+ergency also offers a 'usy< 'ut 'alanced eperience here< although one+ay 'e taken a'ack 'y the sheer nu+'er of patients lying in 'eds placed in the hall#ay(4sychiatry also offers a pleasant eperience #ith a diverse 'alance of patients< 'oth adult andpediatric( $verall< if you desire a change of pace fro+ the large< over#hel+ing sie of the centraltertiary hospitals< SMH presents a great opportunity to 'e so+e#here ne# and en>oy a great carefacility.





S4H" St( 4aulQs Hospital

*ritten 'y Ben>a+in =ong< M! /6),

Edited 'y Ben Tuyp< M! /6)0

St( 4aulsDs Hospital is a large pri+ary care hospital serving the uniFue do#nto#n 3ancouverpopulation( Because of its sie and patient volu+e< you #ill 'e eposed to a #ide variety ofi+portant cases fro+ trau+a to heart failure to +eningitis depending on your rotation( Ho#ever<as a result of its diverse population< these cases are also often co+plicated 'y co+or'idities suchas alcoholis+ or drug a'use( As such infections and other diseases that often result fro+ 73!U<poor hygiene or alcohol a'use +ust also 'e addressed( 7n addition< involving social #ork in thecare of S4H patients is also necessary( $n +ost rotations you #ill part of a large tea+ includingother +edical students< residents and possi'ly fello#s( As a result< your opportunity to interactdirectly #ith staff +ay 'e reduced( Because of its patient volu+e< you can epect to 'usy at S4H(4opular rotations at S4H include 7nternal Medicine< $rthopaedics< Anaesthesia and possi'ly

4sychiatry(

GE 7&G HE8E

St( 4aulDs Hospital is located on the *est side of Burrard Street< 'et#een !avie and Co+o( 7fdriving< allo# for traffic< especially in the +orning and afternoon rush hours( The hospitalDsunderground parking lot is N:(5: per day #ith your 3CH 7!< 'ut it fills up early( Aside fro+ this<youDll 'e spending N):?N,6 to leave your car for the day(

Using transit is a very effect +eans of getting to S4H( The hospital is located )k+ South of theBurrard Skytrain station and )k+ South#est of the Canada Line City Centre station( The V/<//< ,/< 00< and &// 'uses all travel do#n Burrard< and transit along Granville is only 0 'locksa#ay(

7f you are travelling 'et#een other hospitals in 3ancouver< the 7nterHospital Shuttle providesgreat service( This dedicated shuttle runs 5 days a #eek< leaving S4H every ,6 +inutes fro+ 5"6:to 0",: en route to BCCA< 3GH< G% Strong and ChildrenDs( 7n the other direction< arrivals atS4H are every ,6 +inutes fro+ 5",, to 2"6,( Schedule found at###(phsa(ca&8rdonlyres/CA6)!A?%!C6?0B)?::%?

/C21)5%%5)2B6ShuttleSchedule(doc

(Allo# for etra ti+e ho#ever as the syste+ gets 'usy during the day< and there +ay not al#ays 'e

roo+ for +ore passengers(

7f you live in or close to do#nto#n 3ancouver< cycling to S4H +ight 'e the +ost efficient+ethod of transportation( Bike lanes on Horn'y and Burrard +ake S4H an easy destination( A 'ike cage is found in the parkade off Burrard< accessi'le via a 4rovidence 7! #hich can 'eo'tained fro+ Security on the 0th floor of the Burrard 'uilding( There are +any open 'ike rackson street level as #ell(

: The CLE8SH74 GU7!E ; Sites" 3%M4







S $87&G -$U8 S U%%

Lockers for students are availa'le in the call roo+ area @Burrard 1( =ust 'e careful not to use alocker already assigned to another MS7 or resident( Students rotating through 7nternal Medicinealso have access to lockers on the 5th floor of the 4rovidence 'uilding< and those rotating throughE+ergency Medicine are provided lockers 'eside the E! on a first?co+e< first?served 'asis(Students are often not assigned a locker for short rotations( Ho#ever< for +any short rotations

lockers +ay not 'e necessary< as you +ay 'e 'ased out of a nursing station or office that is

sufficiently secure(

EE47&G CLEA&CALL 8$$MSL$U&GE

7n contrast to the rest of S4H< the call roo+s and student lounge is ne# and very co+forta'le(Call roo+s< sho#ers< a +icro#ave< co+puters< a television and a lounge area are all found onBurrard 1( After #alking in the +ain entrance to the Burrard 'uilding< go left and take the firstelevator on your right to the 1th floor( More sho#ers are found #ithin the locker roo+s onBurrard 0< >ust across fro+ the eating disorder clinic( A 4rovidence 7! is reFuired to access 'oththe 1th floor lounge and the 0th floor lockers( -ou #ill need to have your 'adge reactivated after

si +onths of inactivity< so 'ring it to security in the E! as necessary(

HE CA%E E87A

The cafeteria has a decent salad 'ar 'ut other#ise serves 'asic fare such as 'urgers< pia<sand#iches and a daily special( 7t is not #ell revie#ed 'y +ost students( Thankfully< #ith so+any outside options i++ediately availa'le< it can 'e easily avoided(

C$%%EE.

%or a Fuick fi< coffee is sold >ust inside the +ain entrance of S4H and in the cafeteria( $utsideof the hospital< decent coffee can 'e found at Beyond Caf^ #hich is located on the ground floorof the Century 4laa Hotel( ThereDs also a Blen across the street< a Ti+ HortonDs in the gasstation south of the hospital< a Star'ucks at !avie and Thurlo#< and +any other places near'y(

G$$! EA S CL$SE B-

-ou are in !o#nto#n 3ancouver so good food is never far a#ay. A good idea is to head *est on!avie street( There< you can choose fro+ adoya @sushi< Thai Basil< Banana Leaf @SoutheastAsian< 3eraDs Burgers< Su'#ay @/0hrs< Mucho Burrito @East on !avie and others( 7f 'ringing alunch< the call roo+ has a fridge and +icro#ave that are availa'le for students to use(

HE L7B8A 8-

This is located on floor ) of the 4rovidence Building( =ust follo# the signs(

C$M4U E8S

Co+puters are availa'le in the call?roo+ area of Burrard 1 and in the li'rary on 4rovidence )(




$3E8ALL 7M48ESS 7$&

S4H is a large hospital co+posed of t#o +ain 'uildings" Burrard and 4rovidence( The t#o 'uildings are connected on floors )?, 'y an indoor corridor and on the fourth floor 'y an outdoor#alk#ay( The layout not only confuses patients 'ut also students. *ith ti+e< ho#ever< you #illlearn to find your #ay around( An older 'uilding< S4H acts its age as the #ards are oftencra+ped #ith +ultiple patients in the roo+ and often others in the hall#ay( 7n addition< fe# ofthe elevators are in operation at one ti+e and you are therefore advised to take the stairs. !espite

its do#nto#n location< co++uting to S4H can 'e difficult as a result of traffic< lack of parking orcro#ded transit( The staff physicians are kno#ledgea'le and a pleasure to #ork #ith as long asyou can keep pace #ith the de+anding patient load( Because of 'oth its physicians and patientpopulation< S4H is a pri+e site to learn through real cases as opposed to through 'ooks and 7#ould encourage you to spend so+e ti+e there.





3GH" 3ancouver General

Hospital

*ritten 'y Ben>a+in =ong< M! /6),

Edited 'y Charlie hang and Har+an 4arhar< M! /6)0

3ancouver General Hospital is one of t#o tertiary care hospitals in the 3%M4 progra+( Becauseof its sie and patient population< not only does it offer all rotations @ecept paediatrics at thissite 'ut it also offers the possi'ility of seeing a #ide variety of i+portant cases( -ou can epect to#ork #ith larger tea+s at 3GH resulting in less chance of one?on?one ti+e #ith your resident orattending( 4opular rotations at 3GH include e+erg< due to the eposure to trau+a cases< and thesurgical su'?specialties( General surgery at 3GH has 'een given poor revie#s in the past largely 'ecause of the co+petition for $8 eperience #ith other +edical students< residents and fello#s(That 'eing said< ho#ever< your eperience in clerkship is #hat you +ake of it( Through their

enthusias+ and perseverance< those students that are very interested in surgery are often a'le tocreate eceptional eperiences at 3GH for the+selves( The consensus on 7nternal Medicine is+ied( -ou can epect to #ork hard at 3GH carrying a large nu+'er of patients and #orking+ost of the night on call shifts( Ho#ever< you #ill also likely see +any J'read and 'utterK casesulti+ately i+proving your kno#ledge of< and skills in< internal +edicine(

GE 7&G HE8E

3GH is located centrally and unless you are not fro+ the 3%M4 progra+< or slept through all offirst and second year< you should kno# #here it is. There are +ultiple +ethods of co++uting to

3GH(

Although getting to 3GH 'y car is not a challenge< parking in close proi+ity to the 3GH isepensive( %lashing your 7! 'adge at the parkade at )/th avenue and Laurel street #ill grant youaccess on arrival and ensure you pay no +ore than N2(:6 #hen you eit( Although there is alsofree parking 'et#een ):th and /6th these spots are Fuickly filled +aking it difficult to get oneunless you arrive 'efore 65,6( 7 #ould not reco++end parking in the resident only or t#o hourarea for the day as students have kno#n to 'e ticketed and to#ed(

Second only to arriving 'y a+'ulance or helicopter< transit is a fantastic +ethod of co++uting(Several 'us routes run 'y 3GH( Many students rely on the V< V< or V)5( 7n addition to the 'us< the Broad#ayCity Hall stop on the Canada Line is located at Broad#ay and Ca+'ie street<a :?)6 +inute #alk fro+ 3GH(

7f you prefer to pedal your #ay around< a 'ike cage is availa'le in the !ia+ond 4arkade( 7n orderto access the 'ike cage and the ad>oining locker roo+s< you #ill need your 3GH 7! cardactivated 'y security( -ou can also store your 'ike at the Medical Student Alu+ni Center @locatedon the corner of Ash Street and *est )/th Avenue #hich is a , +inute #alk fro+ 3GH(




S $87&G -$U8 S U%%

Storage options depend on your rotation( %or longer rotations such as general surgery andinternal +edicine< lockers are generally provided @although they +ay 'e shared( %or s+allerrotations< you +ay 'e assigned a locker 'y the depart+ent ad+inistrator( Be sure to check yourreporting instructions and orientation docu+ents to find out a'out the storage that you #ill 'e

provided( 7f there is no infor+ation< a friendly e+ail to the depart+ent ad+inistrator or progra+assistant is #arranted( 7f you do not receive a locker< you #ill have to carry your things around#ith you( $n surgical rotations< youDre safe to leave your clothes on a hook in the locker roo+and change into scru's( =ust 'e sure to take your valua'les #ith you( The Medical StudentAlu+ni Center is located very close to 3GH is a good option to store heavy 'ooks or 'icyclehel+ets(

EE47&G CLEA&

The call roo+s on the second floor of the Centennial 4avilion have a sho#er availa'le( To#els

are also provided( $n a 'usy call shift< do your colleagues< your patients and yourself a favourand use it.

CALL 8$$MS

The call roo+s are located on the second floor of the Centennial 4avilion( *hen you start yourrotation and there is in?house call< the progra+ ad+inistrator should provide you #ith the codefor the serviceDs MS7 call roo+( The roo+s lack luury to say the least 'ut you likely #ill not 'eusing the+ any#ay.

HE L$U&GE

&ot 'usyI Ask your attending or resident #hat you can do( Still not 'usy and need a place torela @or recoverI There are a fe# options here( Located near the call roo+s there is a JdoctorDsloungeK #ith a refrigerator and other a+enities( 7n addition to this space there is also an $8lounge @used 'y students pri+arily #hen on a surgical rotation #hich also has a refrigerator and+icro#aves( The $8 lounge is located on the sa+e floor as the cafeteria and the $8 @surprise<surprise( 7t can also 'e accessed fro+ the $8 itself( Getting to the lounge is easy 'ut ratherco+plicated to descri'e in tet( *hen you e+'ark on a surgical rotation< itDs 'est is to ask aresident or another student ho# to get there(

The CLE8SH74 GU7!E ; Sites" 3%M4



HE CA%E E87A

The cafeteria at 3GH is co++enda'le for the fact that it is convenient for on?the?go students(&onetheless< it is so+e#hat epensive for the food you +ay get( Most food ite+s sold at thecafeteria are decent< as they are safe and edi'le( 7t is advisa'le< though< to forgo the pia as itDsover?priced< rather unsatisfying< and +ay cause you so+e digestive disco+fort( So< use the

cafeteria #hen you +ust< 'ut 'e sure to check out Broad#ay Street for so+e delecta'le cuisines(7f you have a longer 'reak @_,6 +inutes< thereDs a nice food court #ithin City SFuare shopping+all< #hich is located on the corner of Ash and )/th( 7t is a'out a :?5 +inute #alk fro+ 3GH(There are also +any nice restaurants on Broad#ay #hich are not +uch +ore epensive than thecafeteria at 3GH 'ut have +uch 'etter Fuality(

C$%%EE.

%or the caffeine fanatics< coffee is availa'le at several locations in and around 3GH( -ou can getyour fi fro+" the cafeteria @not 'ad< 'ut not great< Caf^ A+i on the first floor 'et#een

Centennial 4avilion and =4 To#er @has good coffee< +unchies and sand#iches< Star'ucks andooka at !ia+ond< Ti+ HortonDs @Broad#ay #hich is open /05< and nu+erous other optionsalong Broad#ay Street @e(g( Blen< Caf^ Artigiano(

G$$! EA S CL$SE B-

Take your pick along Broad#ay( So+e nota'le food places include"

Banana Leaf

Ti+ HortonDs*endyDs @/05

Ouinos

Su'#ay

Saravanaa Bhavan @South 7ndian

Thai /05 @near 5?)) on corner of $ak and Broad#ay

7ndian place #ith N: lunch special @near T! Bank and 'us stop on Broad#ay

!onair Spot

Cactus Clu' Sha Lin &oodle House

%ood court in City SFuare shopping +all

Multiple great sushi places near'y

)66 The CLE8SH74 GU7!E ; Sites" 3%M4



HE L7B8A 8-

4ro'a'ly one located so+e#here in 3GH< 'ut youDre 'etter off going to the li'rary at !ia+ond(-ou can also study at the MSAC( There are co+puters and desks availa'le upstairs anddo#nstairs and not +any people use it during the school year( !uring the day +ost people are inclass or on rotation< and at night it is co+pletely e+pty( Ti+es to avoid the MSAC @#hen you are

looking for a Fuiet space are in the afternoonevenings 'ecause events are held at this ti+e yearround(

C$M4U E8S

To check on #ard stuffpatientsD la's< you can use al+ost any co+puter at the nursing stations inthe =4 To#er( To check your e+ail or other non?#ork related things< using a co+puter in!ia+ond is pro'a'ly the +ost guilt?free option( There are other co+puters around 3GH< if yousee no one around< go for it< 'ut keep in +ind that people need to #ork( Avoid using nursingstation co+puters for non?#ardpatient related things during 'usy ti+es @i(e(< +orning rounds<

afternoon rounds( There are also so+e nice co+puters in the do#nstairs lounge at the MSAC(

$3E8ALL 7M48ESS 7$&

3GH is a large hospital 'ut navigating the 'uilding is usually not a challenge and for eachrotation you #ill 'e stationed in a specific location( 7f you #ere a'le to get to 4BL and lectureson ti+e in /nd year< co++uting to 3GH should 'e no +ore challenging( Then again< 1a+ roundscan 'e a different ani+al( The health care tea+ at 3GH including physicians< residents< nursingstaff and others are friendly and a pleasure to #ork #ith so long as you sho# that you are adedicated< keen and respectful student( Being one of the 'usiest sites in 3%M4< 7 reco++end that

you spend at least one rotation there for the variety of eposures and to learn ho# to ecel undersignificant pressure(


)6) The CLE8SH74 GU7!E ; Sites" 3%M4



S7 ES" SM4

GH" elo#na General Hospital(( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ()6,

3=H" 3ernon =u'ilee Hospital(( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( )6:

)6/ The CLE8SH74 GU7!E ; Sites" SM4



GH" elo#na General Hospital

*ritten 'y Aaron Gropper< M! /6),

GE 7&G HE8E

7f you drive< you can park in the lot for N: a day( Ho#ever< parking is very li+ited( There are alsoa fe# 'ike racks< 'ut no 'ike cage(

S $87&G -$U8 S U%%

Lockers can 'e found in the sa+e roo+ as the sho#er( This is definitely not ideal 'ecause ifso+eone is in the sho#er< you canQt access your locker.

EE47&G CLEA&

Sho#ers can 'e found in the sa+e roo+ as the lockers( $< 7 kno# 7 >ust reversed the sentencea'ove( But GH is a s+all hospital P youDll find your #ay( 7 guarantee it.

CALL 8$$MS

There are no call roo+s( *hyI Because there is no call. Although surgery has overnight call< thatis done fro+ ho+e(

HE L$U&GE

There is a roo+ that they clai+ is the student lounge 'ut is really >ust a 4BL style roo+ that isused for rounds and +eetings( There is no fridge or +icro#ave 'ut it does have a co+puter #hich7 suppose can dou'le as a +icro#ave if you leave your food on top of it long enough @kidding ofcourse(

HE CA%E E87A

The cafeteria is on the +ain floor of the hospital( S+all and not very eciting ? serving your 'asics like soups< sand#iches< a daily special and a salad 'ar( *hat #ere you epectingI

C$%%EE.

There is a coffee shop on the +ain floor( $ther#ise< coffee shops eist ):?/6 +inutes a#ay 'yfoot(

)6, The CLE8SH74 GU7!E ; Sites" SM4



G$$! EA S CL$SE B-

4andosy village is a'out a : +inute drive or /6 +inute #alk a#ay and is the closest place forother food options( There is a coffee shop< a pu'< su'#ay and a fe# restaurants( !o#nto#nelo#na is a :?)6 +inute drive north of the hospital( There you can find any fast food chain youcrave and a #ide variety of other options.

HE L7B8A8-

The li'rary is in the Clinical Acade+ic Ca+pus and has lots of co+puters(


)60 The CLE8SH74 GU7!E ; Sites" SM4



3=H" 3ernon =u'ilee Hospital

*ritten 'y Aaron Gropper< M! /6),

GE 7&G HE8E

3ernon is a s+all city and it is possi'le to live close enough to the hospital to #alk every+orning(

7f you are driving< parking can 'e difficult if you donQt co+e early enough 'ut it is veryinepensive" N/day( There is also street parking a short distance fro+ the hospital(

The transit schedule is less than ideal< 'ut there are so+e routes that pass 'y the hospital( Allother routes take you do#nto#n and the hospital is a )6 +inute #alk fro+ do#nto#n( 7f youprefer to ride your 'ike< there is no 'ike cage< 'ut there are so+e 'ike racks in front of the E8(

S $87&G -$U8 S U%%

Students are provided #ith dedicated lockers in the hospital( There are also lockers in the $8change roo+(

EE47&G CLEA&

Sho#ers are also availa'le 'oth in the call roo+s and in the $8 change roo+(

CALL 8$$MS

There are three call roo+s in the ne# to#er" one at the 'ack of E8< one on the fourth floor@+aternitychildrenQs #ard< and one on the fifth floor @7CU( There is also a student call roo+ inthe old to#er on the 0th floor(

HE L$U&GE

There is no dedicated +edical student lounge< 'ut there is a +edical staff lounge on the ,rd floorof the ne# to#er( 7tQs along the sa+e corridor as the $8 change roo+s( There are threeco+puters< a T3< couches< a fridgefreeer< a +icro#ave< and ta'les( There are also free cookies

and coffee daily.

)6: The CLE8SH74 GU7!E ; Sites" SM4



HE CA%E E87A

The cafeteria is located in the 'ase+ent of the old to#er( 7t has odd hours though( 7t is open for 'reakfast and lunch< 'ut closes shortly after )"66p+( 7t is also only open on #eekdays( The pricesare very reasona'le and the Fuality of the food is pretty good( There is also a cafe on the +ainfloor of the old to#er that is open fro+ 61"66 to )"66 every day @7 think it closes an hour earlieron the #eekend( 7t has food< drinks< and snacks< 'ut tends to 'e pricier than the cafeteria(There is a cafe on the +ain floor of the hospital @Crack 4ot( ThereQs another location of the

Crack 4ot do#nto#n(

C$%%EE.

The nearest chain coffee shop #ould 'e Star'ucks at the 'otto+ of the hospital hill< #hich isa'out :66+ fro+ the hospital(

G$$! EA S CL$SE B-

There are +any chain restaurants at the 'otto+ of the hospital hill @*raps< Su'#ay< Earls( 7f

youQre looking to get a#ay fro+ chains< your 'est 'et is along the +ain strip of do#nto#n< a'out0?: 'locks further north fro+ the chain restaurants( There< you can find a good +i of 7ndian<Asian< Greek< Mediterranean food(

HE L7B8A 8-

The li'rary is in the 'ase+ent of the old to#er< near the cafeteria( 7t has a good collection of 'ooks< including all of the reco++endedreFuired 'ooks for clerkship(

C$M4U E8S

There are : co+puters in the li'rary( Although access to the co+puters in the li'rary is verygood< cell phone reception in the li'rary is not great at all(


)61 The CLE8SH74 GU7!E ; Sites" SM4



S7 ES" 7M4

Ca+p'ell 8iver Hospital(( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( )62

Co#ichan 8iver Hospital(( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( )6

LMH" Lady Minto Hospital(( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ))6

S=H" St( =osephQs Hospital(( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( )))

3GH" 3ictoria General Hospital(( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ())/

*CGH" *est Coast General Hospital @4ort Al'erni(( ( ( ( ( ( ( ( ( ( )),

)65 The CLE8SH74 GU7!E ; Sites" 7M4



Ca+p'ell 8iver Hospital

*ritten 'y Grae+e Bock and Ed+ond Li< M! /6)0

GE 7&G HE8E

Ca+p'ell 8iver Hospital is located in the center of the to#n 'ut this does not necessarily +eanthat you #ill 'e living close 'y( %or a place to stay< there are a fe# postings on Med housing andthere are so+e inns near the hospital( Because your co++ute to the hospital +ay 'e outside of#alking distance< a car is strongly reco++ended( Although parking at the hospital is not free<there is plenty of free parking on the street near'y(

S $87&G -$U8 S U%%

Although lockers are availa'le in the hospital< there +ay not 'e any for students to use so 'eprepared to go #ithout one(

CALL 8$$MSL$U&GE

There is no student lounge or student call roo+s 'ut students are free to use the staff lounge#hich has a fe# co+puters< 'ooks< a +icro#ave< and a coffee +achine(

%$$!.

There is a cafeteria in the hospital #ith li+ited options and a s+all coffee shop outside thehospital( There are also so+e grocery stores< a 'akery< a 5))< and so+e restaurants #ithin a )6

+inute #alk fro+ C8H(





Co#ichan 8iver Hospi tal


GE 7&G HE8E

Co#ichan !istrict Hospital is located a +oderate distance fro+ the to#n of !uncan and 'othdriving and cycling are good options for transportation(

S U!E& A8EA

Sho#ers< study space #ith a li'rary< kitchen space< lockers< and call roo+s are availa'le in thestudent area(

%$$!.

There is a cafeteria in the hospital and a 5)) near'y( The to#n of !uncan is a little #ays a#ay 'ut has a variety of options if you find ti+e for a good #alk or have access to a car(





LMH" Lady Minto Hospital


GE 7&G HE8E

Lady Minto Hospital is a / +inute drive or )6 +inute #alk fro+ the to#n centre( To find a placeto stay that is close 'y< students reco++end posting an ad on the Salt Spring Echange @theirversion of Craigslist(

L737&G HE8E

There is no cafeteria 'ut the to#n is close enough to find food and coffee( 7n the hospital< there isa s+all lounge #ith a 'asic kitchen( There are also sho#ers at the nursesD station and outside the$8(


Me+ora'le Mo+ents

Travelling via Helicopter to re+ote %irst &ationsco++unities during +y rural rotation #as unforgetta'le( To

'e a'le to eperience ho# health care is delivered to theseuniFue patients #as hu+'ling and eye?opening( 7t re+inded+e that although there is gla+our in travelling overseas toserve third?#orld populations< #e have a very near to third#orld population >ust hours fro+ #here #e live< study andplay(

))6 The CLE8SH74 GU7!E ; Sites" 7M4



S=H" St( =osephQs Hospital


GE 7&G HE8E

St( =osephDs General Hospital is a )6 +inute #alk fro+ do#nto#n Co+o( A car is useful< 'ut a 'ike #ill do if you stay in Co+o( 7f you drive< parking is N,6 per +onth and you can use a37HA parking pass( The transit syste+ is not reco++ended as it isnDt very regular(

L737&G HE8E

ThereDs no student lounge 'ut the staff lounge has a +icro#ave and fridges( The surgical and+aternity #ards have sho#ers and lockers( The call roo+s are located at the +aternity #ards(

%$$!.

The nearest coffee shop and restaurant is do#nto#n< a )6 +inute #alk fro+ the hospital


))) The CLE8SH74 GU7!E ; Sites" 7M4



3GH" 3ictoria General Hospital


GE 7&G HE8E

3ictoria General Hospital is located along the Trans?Canada High#ay approi+ately /6?/:+inutes #est of U3ic( Because of the distance< a car is highly reco++ended for transportation(Ho#ever< cycling @,: +inutes fro+ U3ic and transit @`)hr #ork if you have the ti+e( 4arking atU3ic is easy if you o'tain a #eekly pass as this allo#s you to you to park any#here including thedoctorDs spots(

S $87&G -$U8 S U%%

Lockers are availa'le for student storage 'ut third years are encouraged to share lockers(

CALL 8$$MS

Call roo+s can 'e found in the 7M4 area ad>acent to the E8physiotherapy area on the groundlevel(

HE L$U&GE

There is a student lounge #ith a+enities including a co+puter< fridge< +icro#ave< sink andcouch( The couch is converti'le to a sleeping cot(

%$$!.

ThereDs a cafeteria in the hospital #ith good lunch options 'ut Ti+ HortonDs has 'etter hours(There are also a fe# coffee shops and restaurants along 7sland High#ay #hich can 'e accessed 'ytravelling south along Hel+cken 8oad(


))/ The CLE8SH74 GU7!E ; Sites" 7M4



*CGH" *est Coast General

Hospital @4ort Al'erni


Edited 'y Christine ang< M! /6)0

GE 7&G HE8E

*est Coast General Hospital is a : +inute drive fro+ do#nto#n 4ort Al'erni and a'out a :?5+inute drive fro+ the doctorsD clinics( 4arking is free and having a car is strongly reco++ended 'ecause it #ill allo# you to get to the hospital Fuickly #hen called( *hile cycling is a goodalternative to driving< transit is not due to its Fuestiona'le relia'ility(

S $87&G -$U8 S U%%

There are no lockers for students< so 'e sure to pack light( $f course< if you forget so+ething<ho+e is never far a#ay. 7f you are in the $8< you can usually use a relief locker in the changeroo+s @no lock(

CALL 8$$MS

There is a call roo+ located ad>acent to the doctorDs lounge(

HE L$U&GEL7B8A8-

The doctorDs lounge is availa'le for use 'y +edical students< and it has a fridge< +icro#ave<couches< a T3< and co+puters( There is a li'rary located net to the doctorDs lounge(

%$$!.

There is a cafeteria in the hospital 'ut the to#n of 4ort Al'erni is very close and has a +uch#ider variety of options( There is a Mc!onaldDs< %C< Su'#ay< !o+inoDs< and +ore #ithin a /?+inute drive(


)), The CLE8SH74 GU7!E ; Sites" 7M4



8$ A 7$&S

7nternal Medicine((( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( )):

4ediatrics(((( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( )/1

Surgery(((( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ),2

E+ergency(((( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( )02

Anesthesia((( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ):2

$rthopedics(((( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( )1:

$'stetrics and Gynaecology((((( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( )5)

$phthal+ology(((( ( ( ( ( (( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( )2,

!er+atology(((( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( )2

4sychiatry((( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( )0

hird -ear Elective((((((((((((( ((((((((((((( ((((((((((((( (((((((((((((( (((( /6,

))0 The CLE8SH74 GU7!E ; 8otations



7nternal Medicine

*ritten 'y Andy Chen< M! /6),Edited 'y La#rence Haiducu and =ackson Chu< M! /6)0

HE B7G 47C U8E" 7& 8$!UC 7$&

7nternal Medicine is one of the Big ,D rotations and is co+prised of 2 #eeks of hospital 'asedclinical service( *ithin these 2 #eeks< activities include inpatient care< outpatient consultationclinics< as #ell as overnight call shifts that occur on a ) in : schedule during #hich students #illco+plete ne# patient consults( Students at the +a>or hospital sites @3GH< S4H< 8CH #ill 'e#orking on care tea+s consisting of /?, +edical clerks< )?/ 7MG residents< )?/ internal +edicine >unior residents @8)< and a senior internal +edicine resident @8/ or 8,< #hich #ill 'esupervised 'y an attending doctor at the hospital(

Although reno#ned to 'e difficult and tiring< it is potentially one of the +ost re#arding rotationsthat students eperience throughout the year( As descri'ed 'y one attending< Jstudents #ill neverhave as +uch responsi'ility for direct patient care placed upon the+ as they #ill receive duringthe internal +edicine rotation(K This is due to the fact that the student +ay act as the pri+arycare coordinator< #ith the supervising +e+'ers of the tea+ relying on your o'servations( Thisresponsi'ility is essential in developing skills as thorough o'servers and critical thinkers< andshould 'e e+'raced to gain the +ost 'enefit and en>oy+ent.

HE CL7&7CS" $U 4A 7E& *EES

Students at all ur'an sites #ill spend / of their 2 #eeks on the internal +edicine outpatient

service in order to increase their 'readth of eperience( This generally involves #orking in aclinic setting alongside an internal +edicine su'?specialist< such as cardiology< gastroenterology<rheu+atology< endocrinology< nephrology< he+atology< and various other fields( There #ill also 'e place+ents #ith general internists< #ho either have areas of special interest such as eatingdisorders< hypertension< pre?surgical health evaluation< etc(< or those #ho +anage co+ple +ulti?syste+ illness patients referred 'y fa+ily physicians for ongoing care(

Students #ill 'e responsi'le for seeing 'oth ne# patients and follo#?ups< gathering data<presenting the infor+ation to the general internist theyDre #orking #ith< and colla'oratingtogether to develop a +anage+ent strategy for the patient( There is also an epectation for

students to co+plete dictations for patients they see in clinic< and have these revie#ed 'y theirattending( Along #ith clinic eperience< there #ill also 'e individualied teaching sessionsrelevant to outpatient consultation services presented 'y the supervising internist(

)): The CLE8SH74 GU7!E ; 8otations



!uring the outpatient #eeks< students #ill not partake in +ost of the inpatient service duties(!epending on schedules< there are so+e opportunities to attend noon rounds as per nor+al< 'ut

there is no epectation for outpatient students to 'e at +orning reportrounds< or to carry anyassigned inpatients( As only ) student fro+ each tea+ #ill 'e on the outpatient service at a ti+e<the re+aining +e+'ers of the tea+ #ill take over for the +anage+ent of the +issing studentDspatients( *ith the eception of #eekends @%riday inclusive< outpatient service students areee+pt fro+ overnight call( This provides a valua'le opportunity for students to have etraavaila'le study ti+e to consolidate their kno#ledge( These / #eeks are essentially a Jcall?free

vacationK opportunity #hen students should either 'e reading ahead to increase their kno#ledge<seeing the ti+e as a 'reak in the +iddle of internal< or using it as so+e +uch needed cra++ingti+e / #eeks 'efore the ea+s( Use it #isely.

Me+ora'le Mo+ents

7nternal +edicine #as +y very first rotation of third year< and 7 found itrather inti+idating( $n one of +y call shifts< 7 #as asked to see apatient in e+ergency #ho had a lot of co?+or'idities and #asco+plaining of shortness of 'reath( Having already 'een seen 'y the

e+ergency physician< the cardiac tea+< and +y internal +edicineattending< and the consensus #as" a C$4! eacer'ation< 'ut 7 #as sentin to do +y @redundant< 7 thought history and physical any#ay( Thepatient told +e the story< #hich included so+e chest disco+fort< andafter 7 #as finished +y ea+< 7 looked up the la's( The e+ergencyphysician had ordered a troponin< of course< and 7 noticed that it #asever so slightly elevated P a'out 2 hours ago( &o follo#?up troponin#as in the syste+( 7 turned to the resident sitting net to +e( J7 kno#this patient see+s to 'e having a C$4! eacer'ation< 'ut the troponinis a little elevated and there #as no follo#?up value( ShouldnDt #e ordera second troponin >ust in caseIK The resident looked through theinfor+ation on the patient and agreed that a follo#?up troponin #as

pro'a'ly a good idea< so 7 put in the order(7 checked 'ack later to see if the result #as in< and it #as( The troponin#as /,( -es< you read that right( T*E&T-?TH8EE( Given that anor+al troponin is less than 6(6:< /, is a really< really high nu+'er( 7had >ust caught an &STEM7( &ot 'ad for a ne#'ie( =ust goes to sho#that so+eti+es< the fresh eyes of a +edical student really can +ake adifference.

Life $utside of Medicine

!espite popular 'elief< there is life

outside of internal +edicine( -ou >usthave to +ake ti+e for it( The +ost

i+portant day during internal +edicinefor +e #as post?call day( $n the day of

call< 7 #ould try to find so+e ti+e to napduring the afternoon #hen it #as not

'usy( $vernight< 7 generally slept verylittle and #oke early to round on

patients 'efore the +orning +eeting(This allo#ed +e to often leave 'efore

noon( After leaving the hospital< 7 #ouldhave a nice lunch< a nap and a free

evening. These evenings often included a+ovie< catching up #ith friends or

+ay'e a >og around 3ancouver( A lot ofprep for a fe# hours of relaation 'ut it

is certainly #orth it.

HE 7 7&E8A8-" S U!E& SCHE!ULES

The schedule varies fro+ site to site< 'ut students #ill #ork Monday to %riday plus call shifts( Atypical inpatient care day #ill 'egin #ith +orning rounds at 2a+< #hich co+prises of a 'riefrevie# of the yesterdayDs status of patients under the care tea+ and the for+ulation of care plansfor the day( St( 4aulDs Hospital students start their +ornings #ith case?'ased teaching roundspresented 'y internal +edicine residents and led 'y the chief resident< and +ay or +ay not +eet#ith their tea+ during the +orning depending on the senior resident(




Students #ill then see their assigned patients @typically /?, at any point in ti+e< check on la'results and other co+pleted investigations fro+ the prior day< and #rite a co+prehensive progressnote in the charts( 7f any further investigations @e( chest ?ray< ECG< additional 'lood#ork< etcis reFuired in a ti+ely fashion< this can 'e ordered as #ell after discussion #ith the seniorresident( %ollo#ing the +orning activities< +any tea+s #ill +eet again 'efore noon fordiscussion rounds to report on the current condition of patients< receive teaching and instructionsregarding the net step of the patient care plan< and #hat should 'e epected or #ill reFuirefollo#?up on during the afternoon(

Lunch ti+e usually consists of noon ti+e interspecialty rounds< in #hich students are epected toattend the presentation delivered 'y a variety of doctors in different fields on selected topics(These sessions provide a great opportunity for students to sit and get a 'reak fro+ the +orning

hecticness< gain ne# kno#ledge< and luckily< eat the free lunch that is often provided at theserounds.

The afternoon varies depending on the day and +ay consist of acade+ic half days @Thursdays<for+al or infor+al teaching sessions 'y the chief +edical resident @CM8< tea+residentsattending< or other hospital staff< and of course< +ore rounds. This last iteration

provides an opportunity to #rap up on patient care outco+es for the day @depending on if+orning investigations that #ere ordered have returned and to ensure that any outstandingissues or concerns can 'e addressed and notified to the on?call tea+ to 'e a#are of( !ependingon the attending< the afternoon rounding +ay involve actually visiting each patient< #here 'edside teaching #ill 'e provided< or si+ply teaching delivered during patient discussion at theta'le( 8egardless of the for+at< students are epected after#ards to #rite a 'rief progress noteupdate on their patients< order any ne# desired investigations< and co+plete any dischargesu++aries they +ay have outstanding( This +eans the day can end any#here 'et#een 0p+ to5p+< depending on #hat needs to 'e done and ho# long the afternoon rounds take(

HE $3E8&7GH " CALL SH7% S

Call in internal +edicine is full day and overnight and occurs on a ) in : schedule @so+e sites+ay have ) in 0 at ti+es( !uring the dayti+e< the senior resident #ill 'e do#n in e+ergency toaccept any consultations that are called in 'y e+ergency depart+ent physicians @E!4 and #illtriage these patients 'ased on acuity< co+pleity< and variety of eperience to a +e+'er of thecall tea+( As this #ill 'e done in a 'alanced fashion< students can epect roughly every 0th to:th patient that is referred to 'e assigned to the+< depending on the sie of the tea+(




$nce assigned< students #ill see the patient< take a co+plete history and physical< for+ulate adifferential diagnosis and preli+inary plan @investigations< treat+ents< ad+ission orders< thenrevie# #ith either the senior resident or staff attending regarding the patient( $nce this revie#has occurred and has 'een discussed< orders #ill 'e #ritten and sent< and the patient #ill either 'e ad+itted to the #ard and 'eco+e assigned to the student for daily rounding< or #ill 'e dee+edfine to 'e discharged or referred to an alternative specialty( The process repeats as patients arereferred to internal +edicine and< depending on the night< each student can epect to doany#here fro+ / to 0 consultations( 7f lucky< these #ill co+e during the dayti+e or early

evening( 7f not< they #ill stack up together after +idnight and sleep #ill only 'e #ishful thinking(Thus it is advised to all students to nap #hen thereDs do#nti+e< and go to 'ed early if one

doesnDt have any pending consults(

The net +orning< ad+itted patients #ill 'e revie#ed #ith the staff attending< +ore +orningorders #ill 'e #ritten< and then assigned patients #ill still 'e rounded on 'y students andrevie#ed #ith the tea+ as per nor+al( Students are officially releasedD post?call 'y noon at thelatest< 'ut in practicality this +ay not al#ays occur as thereDs al#ays #ork to 'e done< and onso+e days students +ay stay until ,p+ or later post?call afternoons(

HE GEA8" *HA $ B87&G 9 CA88-

The choice of #hat to carry around is i+portant< as students can epect to 'e on their feet for agood portion of the day and 'e #alking around Fuite a 'it( Thus less is +ore( Essentials includeoneDs phone and pager< the patient #ard lists< pen and paper< a stethoscope< a #hite coat< and aninternal +edicine reference such as the popular J4ocket MedicineK or JApproach to 7nternalMedicineK 'ooks( Advisa'les include a drug reference +anual< a 'ottle of #ater< and so+eporta'le snacks @e( granola 'ars( Although one could< +ost students opt to not carry theirpenlight< tendon ha++er< and tuning fork #ith the+ @'ut do have the+ availa'le so+e#here incase they 'eco+e reFuired(

S A-7&G 7& HE &$*" HE BES *A-S $ EE4 8AC $%

4A 7E& S A&! $ HE8 7&%$

This co+es do#n to personal preference( So+e choose to #rite directly on the patient #ard lists@although space +ay 'e li+ited< others use scrap paper or coiled note'ooks< and so+e si+ply usetheir +e+ory @although i+pressive< this is unlikely to 'e effective at our level< and is notreco++ended( -ou +ay also #ant to keep track of progress notes and the patientDs currentinpatient +edicine list( This #ay< if one ever needs to refer 'ack to #hat happened yesterday< orlook up Fuickly #hat +edications or dosage the patient is currently on< itDs availa'le at the+o+ent( 7t also helps to +ake checklists #ith 'oes 'eside to?do ite+s for each patient to keeptrack of tasks(




BEC$M7&G A& E4E8 " 8EC$MME&!E! 8EA!7&G

There are a variety of resources availa'le for reading< and #hich one to use is dependent on astudentDs learning style( A 'asic reFuisite is a pocket reference for #hen on the #ards< such asJ4ocket MedicineK @aka( the green 'ook< or #hichever colour corresponds to the edition orJApproach to 7nternal MedicineK 'y !avid Hui( Beyond this< ho#ever< it also helps to have a+ore co+prehensive 'ook for at ho+e reading< and the options vary"

if one likes flo# and details in the tet and infor+ation" Blueprints< Up?to?!ate

if one likes only key facts and +e+ory aids" %irst?Aid< Toronto &otes

if one likes Fuiing O9A #ith eplanations" Lange O9A< 4retest< !e>a 8evie#

if one likes patient?'ased teaching cases" Case %iles

7tDs reco++ended to >ust pick one reference and read that co+pletely initially @e( V) or / a'ove<then follo# that #ith a reference of a different type for practice @e( V, or 0< rather thansi+ultaneously referring to +ultiple sources erratically(

*HA HE HEC *AS HA I" H$* $ S U!- !U87 &G HE

8$ A 7$&

$ne studies any chance they get< in any for+ they can get( This includes day?to?day tasks< suchas during rounds< #hen seeing patients #ith staff or residents< during revie#ing of ne#consultations #hile on call< teaching sessions< or #hen thereDs spare ti+e #ith residents( 7t is alsovery i+portant to learn around patient cases< as this #ill 'oth help to retain the kno#ledge< as#ell as to i+prove oneDs patient care +anage+ent( Both staff and residents are +ore i+pressed#hen students are #ell?versed in their patientDs condition@s and #hat should 'e done regarding

the+< #hich inspires the+ to teach students in +ore detail 'eyond >ust the 'asics(

*hen outside of #ork< co++it to reading a set nu+'er of topics or pages fro+ a 'ook of choiceevery night< and after :?1 #eeks one #ill realie that one has finished the +a>ority< if not all< ofthe 'ook( $n #eekends< take the etra ti+e to go 'ack on #hat #as learned during the #eek andrevie# key facts< such as diagnostic criteria< +ne+onic +e+ory aids< and approaches toconditions( The choice to +ake flashcards is entirely up to individual preference( Although theycan 'e ti+e consu+ing< they do prove useful #hen it co+es ti+e to Fuickly revie# in the #eekprior to ea+s(

%inally< +ake sure to +ai+ie do#nti+e as #ell as the / #eeks of outpatient care. !o#nti+ecan occur #hile on call in the evenings< #hile #aiting for the tea+ to all gather for rounds< or onthe co++ute ho+e( Every little 'it of reading helps.

)) The CLE8SH74 GU7!E ; 8otations



GE 7&G 47M4E!" *HA HE !$C $8S E&! $ AS

Ouestions are usually patient?centred< and +ay relate to co++on presenting sy+pto+s<differential diagnosis< criteria for ruling in or out diseases< and treat+ent+anage+ent plans(They +ay also ask +ore 'roadly applica'le Fuestions such as approaches to interpreting la'

values< chest ?rays and ECGs( 7t is for these reasons that it is helpful to study around patientcases each night in advance of revie#ing the+ #ith staff and residents the follo#ing day(

Being JgrilledK< Jpi+pedK< or Jput in the hot seatK can 'e a nerve?#racking eperience and +aylead to one 'lanking co+pletely in their panic( =ust al#ays keep in +ind that doctors are askingin order to teach< not to e+'arrass( 7f one doesnDt kno# the ans#er< one should ad+it that< then+ake a for+ulated< logical guess at it( At the very least< it sho#s the doctor that one kno#spersonal kno#ledge gaps< 'ut that one can take so+e sort of approach to the pro'le+nonetheless @and often end up pretty close to the right ans#er( 7t is never reco++ended topretend to kno#< as one #ill 'e 'urned 'y this +ore often than not(

There are ti+es #hen Fuestions #ill 'e of the J#hat a+ 7 thinkingIK< in #hich it is difficult forstudents to have any chance at kno#ing or even guessing the correct ans#er( !onDt s#eat or fret

over these Fuestions< they happen< doctors recognie @so+eti+es #hen theyDre asking one ofthese Fuestions< and there isnDt any significant epectation for students to have to get theseFuestions right( =ust give it a 'est guess and once one finds out if it #as right or #rong<re+e+'er to store the ans#er in +e+ory and donDt get caught again net ti+e(

HA&!S $&" 48$CE!U8ES -$U GE $ !$ 7& H7S 8$ A 7$&

The range of procedures one gets to do #ill vary depending on the patients one +anages<enthusias+< and of course< a 'it of luck( Any chance that co+es up to do< or at least o'serve< aprocedure should 'e taken full advantage of< as another opportunity +ay not co+e up again

during the rotation( Co++on procedures that students +ay receive a chance to perfor+ includearterial 'lood gas dra#s< ECG place+ent and interpretation< !8E #ith occult 'lood testing< andfoley catheter insertions( Each of these are #ell #ithin a studentDs a'ilities< 'ut should still 'esupervised and guided 'y an eperienced staff< such as a nurse or resident( $ther less freFuentprocedures in #hich students can o'serve< and perhaps assist #ith< include CS% sa+pling<paracentesis< thoracocentesis< chest tu'e insertion< and >oint aspirations( Be keen and keep on thelook?out for procedures< and one is 'ound to see and do so+e interesting things.

)/6 The CLE8SH74 GU7!E ; 8otations



HE CHECL7S " MUS ?SEES A&! MUS ?!$S HA -$U *7LL

L7EL- GE !U87& G H7S 8$ A 7$&

There is a list of patient encounter o'>ectives availa'le on Medicol and the $ne0: logging pagefor internal +edicine< #hich includes conditions #hich students should have an opportunity to 'einvolved in the +anage+ent of< or at least learn an approach to( These can vary fro+ theco++on such as chest pain< CH%< diarrhea< or ane+ia< to the +ore uniFue such as seiures<thyroid disease< and spleno+egaly( 8egardless of the condition< ho#ever< any student should

have little trou'le covering the +a>ority of these patient encounter o'>ectives through theirinpatient +anage+ent< and any +issing areas can 'e taught 'y residents on reFuest< especiallyduring do#nti+e #hile on call( =ust re+e+'er to log encounters into $ne0: every #eek at+ini+u+< as any longer duration #ill result in one forgetting #hat theyDve seen(

LE3EL7&G U4" H$* $ 48E4A8E %$8 HE EAM

A good portion of learning #ill co+e fro+ on the >o' eperience and teaching sessions #ithresidents and attendings( Ho#ever< there is undou'tedly a need to study on oneDs o#n in additionto these learning opportunities if one is to pass the ea+s( Most students pick a study resource

'ased on personal preference< and in the end the choices are eFuivalent as long as it is +atched tooneDs learning style< and the student actually co+pletes reading the resource(

7t is highly reco++ended to pace the studying right fro+ the start< rather than leaving it to thelast fe# #eeks to cra+( 7f one chooses /?, topics a day to read on during the first 1 #eeks< theyshould find that the +a>ority of topics #ill 'e covered( !uring the last / #eeks< a 'rief overallrevie# of conditions helps refresh and consolidate kno#ledge( A fe# days 'efore the ea+<atte+pt nu+erous &BME style practice Fuestions< in order to 'e accusto+ed to the +indset ofreading and ans#ering Fuestions Fuickly< as #ell as the level of understanding reFuired 'y theea+(

So+e opt to create cue cards on various +edical conditions for easy revie# closer to the ea+(This choice is up to each student< as creating the revie# cards can 'e ti+e consu+ing and +ay

not 'e used effectively later on for studying< 'ut the process of +aking the+ can 'e 'eneficial initself(

)/) The CLE8SH74 GU7!E ; 8otations



HE %7&AL B$SS" E&! $% 8$ A 7$& EAMS

The internal +edicine ea+s consist of an &BME< $SCE physical ea+< and oral case scenarioea+< all occurring during the last #eek of the rotation( Typically the $SCE is at the start of the#eek< and the &BME and oral ea+s are on the last day of the rotation(

The &BME ea+ is a standard )66 +ultiple choice Fuestion ea+ that is provided 'y theA+erican &ational Board of Medical Ea+iners< to 'e co+pleted in a span of / hours :6

+inutes( 16 or greater is reFuired to pass the ea+( Each Fuestion typically consists of apatient vignette illustrating a presenting case #ith associated investigations and results< follo#ed 'y a clinical Fuestion #ith @usually : +ultiple choice selections( As the ea+ is A+erican< thela' values #ill also 'e in US units< 'ut a reference sheet of nor+al la' values #ith 'oth US and S7@international units is provided< and students soon 'eco+e accusto+ed to recogniing #hen ala' value is significantly a'nor+al( The Fuestions are nota'ly longer reads than previouslyencountered MC Fuestions fro+ )st and /nd year +edicine ea+s< and have 'een kno#n tocontain etraneous or ecessive details not reFuired to ans#er the Fuestion( As such< it isreco++ended that ea+inees first gli+pse #hat the Fuestion is asking< then read Fuickly throughthe vignette 'efore providing oneDs 'est ans#er and +oving on to the net Fuestion( Ti+e can 'e

lacking in the ea+ if every Fuestion is read +eticulously and overanalyed. All topics #ithininternal +edicine is covered< 'ut generally Fuestions are focused around diagnostic criteria and+anage+ent of co++on cardiac< respiratory< and gastrointestinal illnessesdisease(

The $SCE ea+ consists of a ,6 +inute session #ith a clinical attending asking the student tode+onstrate various physical ea+ skills on a volunteer patient( A list of ea+ina'le skills isprovided at the 'ack of the internal +edicine clerkship guide< and fall under 0 syste+ categories"cardiovascular< respiratory< gastrointestinal< and other @he+atological< endocrine< neurological<and rheu+atological( The attending #ill only reFuest the student to de+onstrate a specificco+ponent or portion of one of the 0 categories @e( Jde+onstrate ho# to ea+ for =34K or

Jde+onstrate an ea+ for ascitesa'do+inal distentionK< and #ill grade the student 'ased onde+onstrated skills as #ell as interpretation of positivenegative findings( Ho#ever< as theattending +ay ask the student additional Fuestions that could relate to other aspects of eachorgan syste+Ds full ea+ination< as #ell as the fact that the chosen co+ponent is rando+ and atthe #hi+ of the ea+iner< it +eans all aspects of the ea+ for each syste+ still reFuires eFualstudy.

The oral ea+ consists of / stations< each #ith an uniFue case and ea+iner( The student #illread a 'rief case presentation of a patient and Fuickly organie their ideas and plan< 'efore theea+iner enters the roo+ and asks Fuestions related to the case( They #ill provide additionalinfor+ation and la' values< and pro+pt further discussion regarding differential diagnosis<provisional diagnosis< and treat+ent+anage+ent plan( Upon co+pletion< students #ill s#itchstations and co+plete the other case #ith the other ea+iner( Cases are generally 'ased aroundco++on illnessesdiseases that present on the #ard or in e+ergency to internal +edicine< andthe goal is to assure students have a 'asic understanding to diagnosis< and an approach to+anage+ent< of these conditions(

)// The CLE8SH74 GU7!E ; 8otations



HE MA4" S7 E S4EC7%7CS %$8 HE 8$ A 7$&

To find out #here to go on the first day< CHEC -$U8 EMA7L for a +essage fro+ thedepart+ent( Listed is #here students have +et on day one in the past(

Site

S4H 3GH 8CH

*here

students have

+et on day

one in the

past(

Cafeteria conference roo+ on 0th

floor to +eet #ith Chief Medical8esident( EverydayDs +orningreport is also here(

Conference roo+

of )0th floor of=i+ 4attison4avilion(

Medical Education

Center located inthe 'ase+entad>acent to theli'rary< call roo+sand outpatient clinic

*here can 7

store +y

'elongingsI

5th floor #ard A has a +edicalstudent roo+ #ith lockers near thefar 'ack corner( Bring your o#nlock(

There are lockerson 'oth the ,rdand )0th floor forstudents( Seeorientation

+anual(

-ou #ill 'e assigneda locker net to theresidentstudentlounge(

*hat kind of

teaching is

done at this

siteI

Morning report< noon rounds<acade+ic half days< and CM8teaching is standard( There are alsophar+acy and infectious diseaseteaching once per #eek(

Morning report<noon rounds<acade+ic halfdays< and CM8teaching isstandard(

Morning report<noon rounds<acade+ic half days<and CM8 teachingis standard(

7s this a

good site to

choose for

so+eone

interested in

this

specialtyI

Any of the sites are eFuivalent

choices for so+eone interested in7nternal Medicine< as they allprovide good teaching andeposure to a variety of patients(The teaching eperience isso+e#hat rando+ depending onthe Fuality and personalities ofyour attendings and residents(

see left see left

*hat are

co++onuni

Fue pro'le+s

patients at

this site

haveI

-ou #ill see a higher proportion ofdrugalcohol a'use patients here(

M8SA38E is also +oreprevalent here(

There #ill 'enu+erous

co+ple patients#ith +ultipleco+or'iditieshere( $ther#isethe range ofpatients isgenerally #ell

'alanced(

-ou #ill 'e eposedto J'read and

'utterK cases suchas CH%< C$4!<CL!< C! etc(Because of thes+aller patientvolu+e< additionalreading is reFuiredfor +ore o'scurecases

)/, The CLE8SH74 GU7!E ; 8otations



HE L7S " )6 H7&GS $ &$*

: sy+pto+s you #ill need to

kno# the differential and

+anage+ent for"

: things you #ill 'e asked to

interpret de+onstrate an

approach to< or perfor+"

)( chest pain )( reading an ECG

/( shortness of 'reath /( reading a chest ?ray,( G7 'leed ,( perfor+ing a !8E for occult 'lood

0( diinesslightheadedness0( interpret a'nor+al la' values@e(lytes< CBC

:( fever :( interpret 'lood gases @e( acid?'ases<4C$/

HE SUMMA8-" CL$S7&G H$UGH S A&! A!37CE

7nternal +edicine is a tough rotation( ThereDs si+ply no #ay to sugarcoat it( -ou #ill feelstressed< you #ill 'e tired< and you #ill have days #here you #ant to 'reak do#n 'ecause thereDsso +uch to do( Many people do not actually en>oy this rotation< nor do they learn as +uch asthey could have due to ti+e constraints and fatigue( Ho#ever< even those #ho arenDt 7M?inclinedcan recognie the uniFue opportunity provided to actively diagnose and +anage patients< aresponsi'ility that +ay not 'e availa'le again in any other rotation(

8egardless of your interest in this specialty< 'e keen< relia'le< and a+ia'le #ith your tea+< andyouDll find that residents and attendings 'eco+e far +ore enthused to spend ti+e teaching you(7f you donDt understand anything< ask anyone you can for help< including the tea+ phar+acist<

the nurses @they kno# tons.< the physiotherapist or the social #orker( %or the +ost part everyonearound you is #illing and happy to teach +ed students as long as there is ti+e< and as long as thestudent de+onstrates a #illingness and eagerness to #ork hard( 7f you ever donDt kno#so+ething or didnDt do so+ething< donDt try to 'ullshit or lie< youDll 'e caught and the outco+e isfar #orse than ad+itting you have no idea or hadnDt co+pleted that task( !onDt 'e discouragedon the 'ad days< everyone has the+< and you recover Fuickly the follo#ing day if +istakes have 'een +ade(

4ost?call days #ill 'e especially tiring< so donDt feel guilty if you end up sleeping +ost of the

afternoon and evening after you get ho+e< as this is +uch needed if youDre to return to #ork freshthe net day. Given that fatigue can 'e an issue on this rotation< +ake sure you get enough sleepeach night( Also< 'eing 'usy on service< you +ay not al#ays have ti+e to gra' a 'ite< sodefinitely carry so+ething Fuick and easy to eat @e( granola 'ar< 'anana< etc #ith you at allti+es< and there is certainly no sha+e in gra''ing etra leftover food at the end of noon rounds.




As difficult as internal +edicine #ill 'e< 'y the end all students co+e out of it having learned+ore than they couldDve i+agined( They 'eco+e far +ore adept at diagnostic and treat+entskills< and have thus 'eco+e 'etter +edical students 'ecause of it( Even if you donDt like therotation or specialty< youDll still feel like youDre closer to 'eco+ing a doctor than you have ever feltduring the first / years of +ed school.


)/: The CLE8SH74 GU7!E ; 8otations



4ediatrics

*ritten 'y Andy Chen and Leslie Anderson< M! /6),

Edited 'y 8achel Li+< La#rence Haiducu< and Christine ang< M! /6)0

HE B7G 47C U8E" 7& 8$!UC 7$&

4ediatrics is one of the J'ig ,K rotations and consists of a +onth of inpatient pediatrics at a+a>or hospital site @BCCH< LGH< 8CH< or SMH and a +onth of outpatient care in aco++unity or su'specialty clinic( 4ediatrics isnDt >ust applying adult +edicine on a s+aller scale.$ne can al+ost regard pediatrics as a standalone rotation< as the skills and kno#ledge reFuired is

often uniFue to the specialty< so going through internal +edicine or surgery 'eforehand +ay noteven 'e particularly advantageous.

Students #ill 'e sent an e?+ail< a +onth or t#o prior to the start of the rotation< asking the+ to

choose #hich inpatient site and outpatient electives they #ould like for the rotation( As this isfirst co+e< first served< respond Fuickly. Each inpatient site choice co+es auto+atically #ith oneoutpatient assign+ent< and the other outpatient option #ill 'e assigned rando+ly later(

8egardless of #hich hospital site or #hich electives a student chooses< the vast +a>ority ofstudents en>oy their eperiences( Though children can 'e challenging to #ork #ith< they alsopresent an opportunity to have a lot of fun and truly feel appreciated( 4lus< itDs the only specialty#here playing on the >o' actually has its uses.

HE CL7&7CS" $U 4A 7E& $4 7$&S

The +onth of outpatient pediatrics consists of t#o /?#eek electives in a variety of su'specialties(These can occur at various sites< 'ut the +a>ority are at BCCH( !epending on the elective<students +ay 'e involved #ith clinics< inpatient consultation< or seeing ne# patients presenting inthe e+ergency( There is generally no call during the outpatient electives< 'ut depending on thesu'specialty< students +ay 'e a'le to reFuest additional shifts or volunteer to 'e on call if they areinterested( Availa'le options +ay vary fro+ year to year(

Cardiology

@BCCH" a surprisingly 'usy and intense schedule 'ut #ith eposure to so+efascinating conditions

Co++unity pediatrics @various locations" a fairly relaed eperience #ith 'read?and? 'utter peds

!evelop+ental pediatrics

@Sunny Hill

E+ergency @BCCH" fast track and acute care< +ost students find this rotation to 'e veryen>oya'le #ith lots of learning

General pediatrics

@BCCH A+'ulatory" referrals fro+ G4s for co++on pediatricissues< as #ell as follo#?up care for recently BCCH discharged ne#'orns




He+atologic pathology @BCCH" a chill rotation #ith afternoon tea ti+e and aninteresting perspective on 'lood disorders

Multidisciplinary

@various pediatric clinics< such as der+atology< oncology<rheu+atology

&e#'orn unit

@S4H or BCCH" ne#'orn ea+s at deliveries and checking on the 'a'iesin the nursery( Lots of cuteness(

&eurology @BCCH

8ich+ond outpatient clinic

@eposure to a variety of areas in peds

%or the outpatient assign+ents< students do also have the option of applying for a !irectedLearning $ption @!L$( They can choose an area of pediatrics that isnDt offered a+ong theoutpatient options and ask the rotation ad+inistrators if that area #ould 'e accepta'le for part ofthe outpatient eperience( 7f it is< applicants #ill 'e given the na+e of a contact person< and iftheyDre a'le to find so+eone #ho is #illing to take the+ on for ) or / #eeks< then that !L$elective 'eco+es a part of oneDs outpatient pediatric eperience( So+e ea+ples include pedsorthopedics< peds der+atology< peds plastic surgery< and peds anato+ical pathology( 7f one is

interested in a !L$< +ake sure to 'egin the application process early.

Me+ora'le Mo+ents

%irst day on pediatric e+ergency< patientQs triage note states" YChloe <5yo< respiratory distress(Y 7 took the chart< go to #aiting roo+ and calledout for Chloe( Chloe and her father ca+e in to the ea+ination roo+(Chloe looked like a 'ig girl< at least :Q< 'ut #hat the heck< kids aregro#ing up fast no# days((( 7 asked a'out her resp distress< she said shehad a little 'it of S$B #hen she fell at 4E today< 'ut the +ain pro'le+is her sore and s#ollen #rist( $kay< triage +ight have gotten the #rongchief co+plaint(((

So 7 did a hp for resp distress and sore #rist< then revie#ed #ithstaff( Staff took a look at the patient and asked +e Ythis patient is :Q tall<cooperative and articulate< goes to highschool @she #as #earing unifor+fro+ a private school< did you really think sheQs 5IY Turns out< thispatient is ):( 7t >ust happens that day there #ere / ChloeQs in the #aitingroo+< and the 5yo( Chloe #as in the 'athroo+( *hat are the chances(

Lesson" al#ays check surna+eageoccupation to +ake sure you see

the right patient(


7 love to cook and for +e< there is nothing+ore re#arding that eating a good +eal at

the end of every day( 7 +ade a point ofeating #ell despite +y 'usy schedule 'y

'eing organied( 7 created a #eekly +enuand found a store that #ould do a #eekly

shop for +e @at *hole %oods on Ca+'ie< 7 >ust had to s#ing 'y to pick up the

groceries( 7 also prepared everything that 7could ahead of ti+e @pasta< +eats< saucesetc( Then< #hen 7 returned ho+e after a 'usy day< all that 7 #ould have to do #as

co+'ine the ingredients and voila" a dinnerthat does not include !.





The start ti+e for inpatient pediatrics varies fro+ site to site< and +ay 'e as early as 5",6a+@BCCH or as late as a+ @SMH( 7n general< the +orning starts #ith patient rounding #hichcould take until noon or even the #hole day depending on the nu+'er of patients 'eing carried 'y a tea+individual( The day ends late afternoonearly evening( At BCCH< evening handoveris at 1p+ and students usually leave at 5p+( At SMH< M*% afternoons are outpatient clinicsthat end at 0?:p+R TTh is independent study ti+e and acade+ic half?day ending at 0p+( LGH

and 8CH also have afternoon outpatient clinics throughout the #eek< 'ut BCCH is )66 #ardcare( !epending on the site< students +ay have certain days assigned to eperience the &7CU@neonatal intensive care unit or to cover the ne#'orn nurseries and #ards(

The schedule varies for outpatient options and can start early @5a+ for cardiology< or later @a+for general pediatrics( As epected< the day ends at various ti+es as #ell< depending on#orkload and scheduled appoint+ents to the clinic 'ut on average< the typical outpatient cliniconly 'ooks appoint+ents until 0p+(


At BCCH< call shifts are consolidated into a single #eek of night float( This +eans students #illhave the dayti+e hours off @for sleep and report to the #ards for handover at 1p+( TheyDll 'eresponsi'le for all #ard +anage+ent issues and concerns that +ay arise overnight< as #ell asconsults that arrive in the E!< until +orning handover the net day at 5",6a+( $nce handover isco+pleted< they +ay go ho+e for the day 'ut #ill return that night to repeat the process( &ightfloat #eek typically occurs for 1 nights of the assigned #eek and there #ill also 'e / additional#eekend call shifts during the +onth( 7tDs one of the +ost grueling eperiences of ,rd year 'utitDs also the 'est learning opportunity availa'le for pediatrics( As oneDs sleep schedule #ill 'egreatly disrupted 'y the day?night reversal< it is reco++ended to charge up on sleep prior to the

#eek(

At other sites< call is on average ) in 0< scheduled in the typical fashion throughout the +onth(!uring the day< students #ork #ith either the pediatric attending or resident on call to cover

e+ergency consultations or ne# deliveries( $vernight< they are also responsi'le for any #ardissues that +ay arise( The #orkload overnight varies 'ased on the nu+'er of consultations anddeliveries that occur and thus students +ay get a reasona'le night of uninterrupted sleep< +ay 'eup the entire ti+e or +ay 'e regularly #oken every hour( The pediatrician or resident is first callto all deliveries< usually :?)6 +inutes 'efore they occur and typically they #ill page the student#ith the delivery suite nu+'er #hile theyDre on the go( This +eans students shouldnDt 'esurprised if they have less than : +inutes 'et#een #hen theyDre paged and #hen they have torush do#n to the delivery suite to catch upR 'eing a light sleeper and a fast out?of?'edder is anecessity.




HE GEA8" *HA $ B87&G 9 CA88-

There are the usual ite+s one reFuires for +ost rotations< including a stethoscope @#ith apediatric side if possi'le< so+ething to #rite #ith and the patient list or a note'ook to keep trackof patientsD vitalsissues( There are< ho#ever< also so+e uniFue ite+s to pediatrics< such as acalculator @+any pediatric staff use a s+all clip?on one fro+ Staples or an eFuivalent device @e"cellphone< as this is a necessity for calculation of fluids and #eight changes( Another uniFueite+ that often is useful is so+ething cute on oneDs stethoscope< such as a clip?on stuffed ani+al

or toy( *hitecoats are neither reFuired nor reco++ended.


4A 7E& S A&! $ HE8 7&%$

Usually students #ill receive a patient list in the +orning and notes can 'e #ritten directly on thissheet( 7f one needs +ore roo+< a s+all note'ook is helpful( So+e people 'ring sheets pre?printed #ith areas to #rite vitals< fluid ins 9 outs< overnight issues< la' results etc( Anotheralternative is to use cue cards for each patient(


There are a variety of resources availa'le for reading< and #hich one to use is dependent on astudentDs learning style( 7t is up to the student if they #ish to carry a pediatric pocket reference<#hich can 'e useful 'ut not al#ays necessary( There are a variety of pediatric revie# 'ooks for atho+e reading"

if one likes flo# and details in the tet and infor+ation" Blueprints< Up?to?!ate

if one likes only key facts and +e+ory aids" %irst?Aid< Toronto &otes

if one likes Fuiing O9A #ith eplanations" Lange O9A< 4retest

if one likes patient?'ased teaching cases" Case %iles

7tDs reco++ended to >ust pick one reference and read that co+pletely initially @e( V) or / a'ove<then follo# that #ith a reference of a different type for practice @e( V, or 0< rather thansi+ultaneously referring to +ultiple sources on topics erratically(

T#o other references that are highly reco++ended are the online CL744 cases @see 'elo# and

the #e'site###(learnpediatrics(co+

< #hich contains nu+erous pages #ith approaches toco++on pediatric pro'le+s as #ell as physical ea+ination videos to help prepare for the$SCE(

Although the depart+ent provides a pediatric reference 'ook for the rotation< it is long anddense< and +ay not 'e the +ost efficient use of reading ti+e( 7t does< ho#ever< function as apocket 'ook for 'ringing around #hile at the hospital(

)/ The CLE8SH74 GU7!E ; 8otations

http://www.learnpediatrics.com./

http://www.learnpediatrics.com./



*HA A8E CL744 CASES

CL744 stands for Co+puter?assisted Learning 7n 4ediatrics 4rogra+s< and is a series of ,/ onlinecases developed for +edical student learning( Each of these cases are 'ased on a si+ulatedpediatric patientR infor+ation regarding history< sy+pto+s< and physical findings are providedseFuentially< si+ilar in style to 4BL cases( 7nterspersed #ith this infor+ation are Fuestions posedto the reader to sti+ulate critical thinking and learning along the #ay( Each case reFuires roughly,6?06 +inutes to co+plete( There are also case su++aries do#nloada'le at the end of each case

that serve as si+ple revie# sheets for the ea+s( *hile co+pleting the cases< it is reco++endedto read each of the Jepert adviceK #indo#s for each section of a case( Although at ti+es theinfor+ation there +ay 'e redundant or o'vious< it still helps to read these #indo#s< as onoccasion< there is useful or interesting kno#ledge that they provide(

Log?in access to these CL744 cases #ill 'e provided 'y the depart+ent @they #ill e?+ailinforo+ation or it can 'e found in the pediatrics +anual( Students #ill 'e reFuired to co+pleteat least /6 of the ,/ cases @no +arks associated< for co+pletion only( Ho#ever< as they are allhelpful< it is highly reco++ended to co+plete all of the cases< as statistics sho# the nu+'er ofCL744 cases co+pleted correlates to a studentDs &BME +ark( 7f one #as to #ork through all of

the online cases< then al+ost every +a>or pediatric condition that students are epected to kno##ill 'e covered( At a pace of one case each day< students could #ork through all of the+ #ithina +onth( They can then utilie the /nd +onth to revie# these cases and other study +aterial(

A list of the cases 'y topic and +ore infor+ation regarding CL744 can 'e found athttp"###(+ed?u(orgvirtualZpatientZcasesclipp (


8$ A 7$&

As #ith any rotation< itDs i+portant to +aintain a steady pace of studying throughout therotation to avoid 'eing over#hel+ed 'efore ea+s( 4ediatrics has a lot to learn and the 'est #ayis to center oneDs studying around patient cases that are encountered( Try to read a'out variousconditions as you encounter the+< and re+e+'er to co+plete the CL744 cases steadily throughthe rotation to cover a #ide variety of topics(

Take careful note of ho# fluid status and feeding#eight gain is evaluated and +anaged thenapply this kno#ledge to su'seFuent patient cases( At all ne# deliveries< perfor+ the full ne#'ornassess+ent #ith the attending or alone even if it has already 'e done 'y the pediatrician as the+ore one atte+pts these ea+s< the +ore efficient and co+forta'le one #ill 'e #ith the+(

),6 The CLE8SH74 GU7!E ; 8otations

http://www.med-u.org/virtual_patient_cases/clipp/

http://www.med-u.org/virtual_patient_cases/clipp/



GE 7&G 47M4E!" *HA HE !$C $8S E&! $ AS

The +a>ority of Fuestions #ill 'e patient case 'ased and #ill occur during rounding( A co++onfocus for all ne#'orns and infants is appropriate feeding< #eight gain< urine output< etc( @see JThenu+'ers of pediatricsK section 'elo#( $ther Fuestions #ill focus on ho# to differentiate 'et#een co++on pediatric conditions such as 8S3< croup and asth+a( !etailing oneDs approachto treat+ent and +anage+ent is also i+portant and often this involves careful +onitoring offeeding to ensure appropriate #eight gain< or the provision of nasal prong oygen to +aintain $/

sats( !uring ne#'orn deliveries< epect Fuestions regarding A4GA8 assess+ents< ne#'ornea+s and possi'le ante? or post?natal co+plications( The latter< for ea+ple +ay relate to intra?uterine gro#th restriction @7UG8< +acroso+ia< transient tachypnea of the ne#'orn @TT&< orrespiratory distress syndro+e @8!S(

HA&!S $&" 48$CE!U8ES -$U GE $ !$ 7& H7S 8$ A 7$&

Students +ay not get to do very +any procedures during pediatrics< as #orking #ith childrentends to 'e a 'it +ore sensitive than #ith adults and has +ore risks involved #ith ineperience(Ho#ever< one +ay get to see or assist #ith starting 73s< perfor+ing lu+'ar punctures< inserting

&G tu'es and ad+inistering vaccinations< depending on the area of pediatrics involved(


L7EL- GE !U87& G H7S 8$ A 7$&

There is a list of patient encounter o'>ectives availa'le on Medicol and the $ne0: logging pagefor pediatrics< #hich includes conditions that students should have an opportunity to 'e involvedin the assess+ent of< or at least learn an approach to( 7t is generally not difficult to co+pletethese o'>ectives< especially #hile on call( Should there 'e any activities not o'served orperfor+ed< one can approach residents and attendings to provide a 'rief teaching session on

these topics(


Use the inpatient eperience and learn around each case and presentation then apply #hat onekno#s to each re?iteration of a case that arises( There should also 'e plenty of ti+e during theoutpatient +onth to study and co+plete CL744 cases and< as long as a steady pace is +aintained<there should 'e no reFuire+ent for cra++ing 'efore the ea+( Case %iles for 4ediatrics #as apopular 'ook< #hile 4retest 4ediatrics #as helpful for practice Fuestions( The acade+ic half?daysalso cover a lot of the +a>or topics as #ell< so it is #orth#hile to attend(

The fe# days 'efore the ea+< it is also reco++ended to revie# so+e of the +ore specialiedpediatric topics that one +ay not have encountered during oneDs inpatient eperience< such aspediatric he+atologyi++unology< genetically inherited conditions and develop+ental orneurological conditions( These topics +ay arise on the &BME and #ithout having so+efa+iliarity #ith the su'>ects< it is Fuite difficult to discern the correct ans#ers( $ther +oreco++on su'>ect areas should have 'een consolidated already over the t#o +onths into oneDsrepertoire of kno#ledge and thus #ould only reFuire a 'rief refresher as needed(

),) The CLE8SH74 GU7!E ; 8otations



HE %7&AL B$SS" E&! $% 8$ A 7$& EAMS

The pediatric ea+s consist of an &BME and $SCEoral ea+< 'oth occurring during the last#eek of the rotation(

The &BME ea+ is a standard )66 +ultiple choice Fuestion ea+ that is provided 'y theA+erican &ational Board of Medical Ea+iners to 'e co+pleted in a span of / hours :6+inutes( 16 or greater is reFuired to pass the ea+( Each Fuestion typically consists of a

patient vignette illustrating a presenting case #ith associated investigations and results< follo#ed 'y a clinical Fuestion #ith @usually : +ultiple choice selections( As the ea+ is A+erican< thela' values #ill also 'e in US units< 'ut a reference sheet of nor+al la' values #ith 'oth US and S7@international units is provided and students soon 'eco+e accusto+ed to recogniing #hen a la'value is significantly a'nor+al( The Fuestions are nota'ly longer reads than previouslyencountered MC Fuestions fro+ )st and /nd year +edicine ea+s and have 'een kno#n tocontain etraneous or ecessive details not reFuired to ans#er the Fuestion( As such< it isreco++ended that ea+inees first gli+pse #hat the Fuestion is asking< then read Fuickly throughthe vignette 'efore providing oneDs 'est ans#er and +oving on to the net Fuestion( $ne can runout of ti+e if one +eticulously reads and overanalyes each and every Fuestion.

The $SCEoral ea+ is in a +ulti?station ea+ for+at that includes a history station< a physicalstation< a counselinggiving of infor+ation station @e( 'reastfeeding< and t#o #ritten stations#here participants #ill 'e asked to interpret la' data< an i+age< graphical data< etc( The $SCEtends to stick to the 'read?and?'utter pediatric issues and +ost people perfor+ Fuite #ell duringthis ea+(

),/ The CLE8SH74 GU7!E ; 8otations



HE MA4" S7 E S4EC7%7CS %$8 HE 8$ A 7$&

To find out #here to go on the first day< CHEC -$U8 EMA7L for a +essage fro+ the depart+ent( Listed is #herestudents have +et on day one in the past(

Site

*here students

have +et on day

one in the past"

*here can 7

store +y

'elongingsI

*hat kind of

teaching or

acade+ic

sessions are

there at this siteI

7s this a good site for

so+eone interested in

this specialtyI

*hat are co++on

pro'le+s patients

at this site haveI

*hat is the call

schedule likeI

BCCH

Go to the #ards onthe ,rd floor @,Mand +eet yourresidents at the+ain desk @alsocalled The %ishBo#l< 'ecause thearea is enclosed inglass for handoverfro+ the nighttea+( There aret#o different tea+s? 'oth take generalpediatric patients< 'ut the Blue Tea+takes cardiacpatients and theGreen Tea+ takesnephrologypatients(

-ou can use thelockers in thelocker roo+ on the/nd floor @youDll 'esho#n #here it isduring orientation< 'ut +ost students >ust put their coat9 'ag under one ofthe desks in the+ain area(

The residents doteaching #hen theycan( -ouDll get the+ost teaching #henyou do your nightshifts< since theresidents #ill have+ore ti+e to teach(-ouDll also go toGrand 8ounds on%riday +orning andAdvances in4ediatrics< ahospital?#ideteaching session< on%ridays at noon(

-es and no( -ouDll geteposure to so+e of thecraier health pro'le+s< 'utyou +ight not spend +uchti+e directly #ith theattending< so getting areference letter +ay 'e+ore difficult( -ou also+ight 'e turned off of pedsif you do CTU at BCCH ?itDs Fuite intense and notreally representative of#hat peds is as a specialty(

Bronchiolitis< !A<nephro pro'le+s andcardiac issues( All rarediseases and uniFueconditions in BC #illlikely 'e transferred toBCCH for care and+anage+ent as #ell(

-ou #ill do 1 nightshifts in a ro# andt#o #eekend days@one Saturday andone Sunday($ther#ise< you#ork Monday to%riday 'ut the dayscan 'e long< startingat 65",6 and goinguntil evening hand?over is finished<#hich can 'e )2",6or later.



Site

*here students

have +et on day

one in the past"

*here can 7

store +y

'elongingsI

*hat kind of

teaching or

acade+ic

sessions are

there at this siteI



this specialtyI

*hat are co++on

pro'le+s patients

at this site haveI

*hat is the call

schedule likeI

SM H

The first day #illstart #ith a siteorientation #ithBar'ara Gourley<the site education

coordinator( Heroffice is in theCreekside 'uildingon 0A Avenue 'ehind the +ainhospital 'uilding(Each +orningafter that< studentsreport to the +aindesk at C-S @Childand -outhServices to divideup patients andstart rounding(

There are lockersfor students 'y thecall roo+s on the/nd floor of Area %@orange line(

Students can alsodrop their 'ags offin the residentsDoffice at C-S orunder the ta'le atthe +aindesknursesstation(

As the one pediatricresident at SMH isgenerally too 'usy#ith the ne#'ornand &7CU suites to

provide teaching tostudents< the+a>ority of learning#ill 'e during therounds oninpatients each day#ith the attending@pediatrician of the#eek( There arealsovideoconferencedacade+ic half?days<grand rounds< andAdvances in4ediatrics sessions(

SMH is very suita'le forstudents interested in 'readand 'utter pediatrics< orthose planning to have apediatric heavy patient

population in their fa+ilypractice clinic( Althoughthere are no rare or uniFuediseases that present usually@these go to BCCH< SMHprovides a+ple opportunityto learn and practice caringfor the +ost co++onpediatric conditions(

8espiratory" 8S3<croup< asth+aG7" poor feeding<vo+iting< diarrheaother" seiures< rashes<

>aundice

SMH has the /ndhighest nu+'er ofdeliveries in BC@after BC* and anetre+ely 'usy

pediatric e+ergencyunit< and thus there#ill 'e plenty ofaction going onduring call shifts($n?call is in?house<approi+ately )"0(

8CH

-ou #ill receive ane+ail prior to yourrotation indicating#here you should+eet

Lockers areavaila'le in theresidents loungearea in the 'ase+ent

8esidents are verygood at +akingti+e to teach( 7naddition< the staffare also very #illingto teach( Theacade+ic half daysare very useful

Because of the s+all sie ofthe pediatric depart+entand the li+ited nu+'er ofpatients that you #ill seeeach day and during call<these sites +ay not 'e idealfor students interested inpediatrics( Ho#ever< 'ecause you #ork closely#ith staff< 'oth sites aregreat for o'taining+eaningful references(

8espiratory" 8S3<croup< asth+aG7" poor feeding<vo+iting< diarrheaother" seiures< rashes< >aundice 8espiratory"8S3< croup< asth+aG7" poor feeding<vo+iting< diarrheaother" seiures< rashes< >aundice

Calls are in?house<)"0(



Site

*here students

have +et on day

one in the past"

*here can 7

store +y

'elongingsI

*hat kind of

teaching or

acade+ic

sessions are

there at this siteI



this specialtyI

*hat are co++on

pro'le+s patients

at this site haveI

*hat is the call

schedule likeI

LGH

8eport to !r(Glenn 8o'ertson at6266?62,6 hrs on ,East @4ediatrics(E+ail #ill 'e sent

out for eact ti+e(

Lockers areavaila'le in the!octorDs lounge in+ain lo''y @lockincluded< in the

nurseDs lounge on,East @novalua'les< and onla'or and deliveryfloor @clothes only<no lock(

Teaching ? )/ dayat BCCH is videoconferenced as isGrand 8ounds andAdvances in

Se+inar !< acrossfro+ li'rary atLGH( Most #eeks<, hours of teachingis offered in aschedule session#ith !r( 8o'ertson(

A'solutely< #ork ) on )#ith staff( Lots of goodopportunities to see #hatGeneral peds is like( Goodopportunity for reference

letters(

7npatient ? pneu+onia<dehydration<gastroenteritis< >aundice< +econiu+deliveries< pre+aturity<

feeding issues< UT7< c?section< fetal heart ratedistress< +edicallyunsta'le eatingdisorders$utpatient ?develop+ental@A!H!< autis+<asth+a< UT7<ece+a< failure tothrive @%TT dia'etes@dia'etic clinic #ith drstock< +edically sta'leeating disorder<+ur+ur< orthopedic

issues< #ell child care(

$n?call is in?houseand approi+ately)"0?:( Typically /#eekenddays(!uring the on?

call hours< students#ill 'e present atne#'orn deliveries@,/ #eeks up#ardand see a variety ofpediatric consults(



HE MA H" &UMBE8S $% 4E!7A 87CS

,6 gday ne#'ornsinfants should gain approi+ately this a+ount of #eight per day

)6ne#'orns can lose up to )6 of their 'irth #eight in the first #eek< 'ut shouldregain this or +ore 'y the /nd #eek at the latest

/6 kcaloenergy content of 'reast+ilk and standard for+ula @E/6( Higher energy for+ula

+ay 'e E// or E/0 @//kcalo or /0kcalo respectively()66?):6+Lkg

adeFuate a+ount of fluid intake @ie( 'reast+ilk< for+ula< 73 solutions per day fora ne#'orninfant to re+ain properly hydrated( Use the )66?:6?/6 +Lkg rule(

1?2day nu+'er of #et diapers per day in an adeFuately hydrated infant

)?/+Lkghr

adeFuate a+ount of urine output for a ne#'orninfant( This can 'e deter+ined 'y #eighing #et diapers and deducting the dry diaper #eight(

:?)6?):,?1?

infant @[/6kg" #eight loss in +ild ? +oderate ? severe dehydrationchild @_/6kg" #eight loss in +ild ? +oderate ? severe dehydration

)

the nu+'er of chances you get to earn and keep the trust of a child( !onDt sayso+ething #onDt hurt if it #ill @a(k(a( shots< donDt say so+ething #onDt taste 'ad ifit does @a(k(a( anti'iotics< and donDt pro+ise you #onDt do so+ething that youkno# youDll have to @a(k(a( physical ea+inations(

HE L7S " )6 H7&GS $ &$*

: co++on pediatric issues to kno#

a'out and differentiate

: aspectsparts of a pediatric history that

you shouldnDt forget to c over @depending on

patient

)( respiratory pro'le+s @croup< 8S3 andasth+a

)( develop+ental history @ie( +ilestones< delays<failure to thrive

/( fluidfeeding pro'le+s @dehydration< no#eight gain

/( pregnancy and 'irth history @ie( co+plications<drug and Et$H use< A4GA8s< prepost?natal care

,( seiures @fe'rile vs non?fe'rile ,( ins and outs history @ie( fluid intake< eating<diuresis< 'o#el +ove+ents< #eight gain

0( G7 pro'le+s @vo+iting< diarrhea andconstipation

0( HEA!SS assess+ent @ho+e< educatione+ploy+ent< activities< drugsdiet< safetysuicide

:( physical in>uries @'urns< trau+a< anda'use

:( infor+ant and social history details @ie( #hoDsproviding info< #ho lives at ho+e< ho#Ds schoolI





Many students are scared of pediatrics as it is a ne# and foreign #orld of +edicine( &ot only isthere the pressure of treating ill children< 'ut there are the difficulties of #orking #ith concernedparents as #ell( So+e students have difficulties kno#ing ho# to appropriately interact #ithchildren or teenagers during the intervie#( These are not skills that co+e naturally to all 'ut can 'e i+proved through o'servation and practice( *atch children play< o'serve ho# they interact#ith their parents and environ+entR Tailor your approach to the age group of the patient 'ut this

isnDt to say that you should patronie or ignore childrenteenagers during the intervie#< as theyare usually far +ore astute and intelligent than they receive credit for( 7nstead< avoid +edicaleseand >argon< ad>ust your voice tone to 'e #ar+ and friendly< get do#n on your knees or into asFuat to 'e at their level and s+ile.

Although during the first #eek or so of the rotation< you +ay feel co+pletely lost and confused inthe foreign territory that is pediatrics< it doesnDt take long to get the hang of the specialty and youcan focus on learning for the rest of the rotation( Also +ake sure you stay on the good side ofthe nurses( TheyDre etre+ely kno#ledgea'le and they can also 'e rather protective andterritorial of their pediatric patients( 7ntroduce yourself early on< 'e courteous< genuine and

relia'le and youDre far +ore likely to receive help fro+ the+ rather than 'eing pushed aside 'ecause they donDt trust your care and skills(

There is lots to learn< +uch that students can do to help< and definitely tons to en>oy. 4ediatricscan often 'eco+e the +ost re#arding of eperiences a+ong all the rotations during ,rd year(This occurs regardless of the outco+e of the patient case< as not every case has a happy ending<

'ut #ith co+passion and enthusias+ for providing the 'est possi'le care to sick children< 'othyour patients and their parents #ill appreciate you i++ensely in the end(





Surgery

*ritten 'y Andy Chen< M! /6),Edited 'y 8achel Li+ and La#rence Haiducu< M! /6)0

HE B7G 47C U8E" 7& 8$!UC 7$&

Surgery is one of the J'ig ,K rotations< and is co+prised of 0 #eeks of general surgery serviceand 0 #eeks total of su'specialty electives @students rotate through / electives< each / #eeks induration( The order of #hether a student has their general surgery +onth first or su'specialties+onth first is assigned 'y the progra+ coordinator( !uring the general surgery portion of therotation< students #ill 'e part of a tea+ along #ith other students< residents< and attendingsurgeons and #ill 'e responsi'le for the pre? and post?operative care of surgical patients< as #ellas o'serving or 'eing involved #ith surgeries( The su'specialty electives @selectives offer a choiceof fields< each #ith their o#n schedule< activities< and responsi'ilities(

8eno#ned for having the earliest start ti+e of any rotation< it truly +akes students appreciateand +iss 2a+ start ti+es for )st and /nd year 4BL( The rotation provides students anopportunity to appreciate #hat general surgery involves and offers a gli+pse of uniFuesu'specialties that +ay 'e of interest( 7t also offers the chance for students to 'e involved as /ndassists @so+eti+es )st if youDre lucky during surgical procedures< putting you up close andpersonal to the internal cavities of the hu+an 'ody( 7t also gives students a chance to practicetheir suturing and tying skills until it 'eco+es second nature.

HE CH$7CES" SUBS4EC7AL - ELEC 73ES @SELEC 73ES

4rior to the start of the surgery rotation< students are offered the opportunity to rank theirpreferences for various selectives< each / #eeks long(The options include @availa'ility of hospital sites +ay vary fro+ year to year"

Cardiovascular Surgery @S4H< BCCH

&eurosurgery @3GH

4ediatric General Surgery @BCCH

4lastic Surgery @3GH< S4H< 8CHSMH

$tolaryngology @3GH< S4H< BCCH

8adiation $ncology @BCCA?3an< BCCA?Surrey

Thoracic Surgery @3GH

Urology @3GH< S4H< BCCH< LGH

3ascular Surgery @3GH< S4H




!escriptions of each selective can 'e found on Medicol under -ear , ?_ Surgery(

Each selective has its o#n uniFue eperience and students should rank according to theirpersonal interests( Like +any other ranking lotteries< place+ent in eactly #hat one #ants is notguaranteed< 'ut generally +ost students receive their top preferences( Although students +ay not 'e eposed to the other selectives< the acade+ic half day lectures #ill cover topics #ithin thosespecialties< and thus those areas are still testa'le +aterial for the end of rotation ea+s(

Me+ora'le Mo+ents

7 started +y surgery rotation in the su'specialty of thoracics< #here 7 learned that the $8s are kept Fuite cold inorder to keep the surgeons< #ho tend to overheat in their Gorte go#ns under those 'right lights< cool( *hen 7started +y net su'specialty< pediatric general surgery< 7 learned that since 'a'ies canDt regulate theirte+perature very #ell< the $8s in those cases need to 'e kept +uch #ar+er] and 7 soon discovered #hykeeping the roo+ cool is so +uch 'etter for the surgeons.

7 #as scru''ed in as second?assist on a 'o#el surgery for a pre+ature 'a'y( Since our patient #as so tiny< thesurgeons and 7 #ere cra++ed against each other< and also against the Baer Hugger @an inflata'le #ar+ing padthat the 'a'y #as lying on( 7 #as in charge of holding a retractor< and 7 had to hold it up in the air< 'ecause if 7

let it rest on the patient< it shifted the tu'es 'ringing oygen to the 'a'y( So< 7 #as in an a#k#ard position#earing full go#n and gloves under hot lights and pushed up against a hot #ar+ing pad and the 'ody heat ofother surgeons< and 7 started to feel #eird( %irst< 7 noticed s#eat starting to drip do#n +y 'ack( Then 7 felt kindof lightheaded( Then the nausea kicked in( 7 kept taking slo# deep 'reaths< telling +yself 7 #as >ust fine< 'ut 7really #asnDt( 7 #as Fuickly reaching the point #here 7 #as going to pass out< so 7 finally had to tell everyonethat 7 #as overheating and needed to step a#ay fro+ the ta'le( 7 sat do#n on a stool and put +y head 'et#een+y legs( 7 #as still so #ar+< so 7 took +y go#n and gloves off( My scru's #ere soaked #ith s#eat( Another#ave of nausea hit and 7 needed to run out of the roo+( A nurse follo#ed +e to +ake sure 7 #as okay( Shepointed out that 7 #as as #hite as a sheet and #ent to go and get +e so+ething to eat( Another couple ofnurses #ere in the change roo+ #here 7 ended up< and they +ade +e feel 'etter 'y sharing their stories of #henthey al+ost passed out in the $8 P apparently it happens to al+ost everyone at least once. The nurse ca+e

'ack #ith so+e >uice< cheese< and a grape popsicle @the 'enefit of 'eing at ChildrenDs Hospital. and 7 started to

feel a 'it +ore nor+al< al'eit a tad e+'arrassed( 7 definitely ca+e to appreciate the cold te+perature of adult$8s] and 7D+ really glad 7 didnDt pass out on our patient.


!uring general surgery< the typical day starts #ith +orning rounding on pre? and post?operativepatients 'efore the operating roo+ @$8 starts( The precise ti+e varies fro+ site to site< 'uttypically +ost $8s start at 2a+< #ith patients prepped and ready 'y 5",6a+( Because of this<

rounding can start as early as 1",6a+< depending on the nu+'er of patients the tea+ has( Afterrounds< the day varies depending on the assigned duties of the student( So+e days the student+ay 'e scheduled for the $8< during #hich they scru' in and o'serveassist the surgeons andresidents( $thers #ill involve day clinics in surgeon offices< in #hich ne# consultations or follo#?up patients #ill 'e seen( Acade+ic half?days occur every Tuesday and Thursday afternoon( $ncall days< students #ill 'e on site to take any e+ergency consultations or #ard calls( Most non?call days< students #ill 'e done 'y 0 or :p+ in the afternoon(

), The CLE8SH74 GU7!E ; 8otations



The #eeks of su'specialty electives each vary in regards to their schedules and startend ti+eseach day< 'ut in general #ill follo# the sa+e +i of activities such as $8 ti+e< outpatient clinics<and call(


Surgery call is full day and overnight< and generally ends once patient rounds have 'eenco+pleted the follo#ing +orning( 7t is on average< ) in 0< 'ut varies fro+ site to site( 7n general<

call is co+pleted #ith a resident and attending< #ho are first?call for e+ergency consultations(They #ill then prioritie the calls and assign the student to see the patients as needed( The

purpose of surgery consults is to dee+ #hether a patient reFuires surgery acutely< if they reFuiread+ission and +onitoring< if they can 'e sent ho+e safely< or at ti+es< if they arenDt even asurgical case at all and another service should 'e called. 7n the first case @generally appendicitisor trau+a cases< these patients are often scheduled for e+ergency surgery< regardless of the ti+e<and thus students +ay find the+selves in the $8 at ,a+ or any other ti+e of the night.

Students +ay also receive #ard calls fro+ nurses to assess patients during the shift< the reason for#hich +ay vary fro+ co++on internal +edicine issues @e( chest pain or +ore surgery related

issues @e( vo+iting< patient pulled their nasogastric tu'e( After seeing the patient< students #illrevie# #ith the resident and +anage accordingly(

As a result of the on?call activity varia'ility< students +ay find they get a full nightDs sleep< or 'ea#ake all night seeing patients in the E! and standing in the $8(

HE GEA8" *HA $ B87&G 9 CA88-

Typically not +uch is reFuired during the day #hen rounding( A pen< so+e paper< and astethoscope is often enough to co+plete patient rounds or e+ergency consultations( *henstudents are in the $8< little needs to 'e carried other than a pen and oneDs pagerphone to takeconsults if one is on call( As scru's #ill 'e the nor+al attire for $8 days< it is difficult to carryany reference 'ooks in the li+ited pocket space( Also< keep in +ind that any #eight one carriesin the $8 is #eight that one #ill 'e holding up #hile standing for possi'ly hours at a ti+e.


4A 7E& S A&! $ HE8 7&%$

Generally a patient #ard list #ill 'e printed each +orning for the +e+'ers of the tea+< andovernight handover issues can 'e #ritten on this directly( Generally having a sheet of scrap paperavaila'le at all ti+es is also useful to >ot do#n Fuick notes or #rite do#n infor+ation #hen

ans#ering consult pages(

)06 The CLE8SH74 GU7!E ; 8otations




There are a variety of resources availa'le for reading< and #hich one to use is dependent on astudentDs learning style( Most students donDt feel a need to carry a surgery specific pocket 'ookduring the day< 'ut having an internal +edicine reference #hile on call could occasionally 'ehelpful if there are certain #ard issues that arise( $ne should have one or +ore surgery revie# 'ooks for at ho+e reading though< and the options vary"

if you like flo# and details in the tet and infor+ation" Blueprints< Up?to?!ate

if you like only key facts and +e+ory aids" %irst?Aid< Toronto &otes

if you like Fuiing O9A #ith eplanations" Lange O9A< 4retest< 4estana

if you like patient?'ased teaching cases" Case %iles

7tDs reco++ended to >ust pick one reference and read that co+pletely initially @e( V) or / a'ove<then follo# that #ith a reference of a different type for practice @e( V, or 0< rather thansi+ultaneously referring to +ultiple sources on topics erratically(

Although the surgery depart+ent provides / tet'ooks to students for reference< the generalconsensus is that these 'ooks are too dense and detailed to 'e high?yield reading< and thus oneshould use an alternative source unless there are eor'itant a+ounts of free ti+e availa'le. Thecaveat to this is that the first / to , chapters of the general surgery 'ook focusing on pre? and post?operative +anage+ent can 'e useful for the &BME ea+< and that the su'specialty 'ook +ay 'ea reasona'le reading resource if oneDs revie# 'ook of choice does not contain a good chapter ononeDs surgery selectives(


8$ A 7$&

7t helps very early on during the general surgery +onth to 'eco+e #ell?versed in co++onpresentations of surgical conditions @see J)6 thingsK 'elo# as #ell as ho# to +anage the+< as it+akes oneDs call shifts far easier and +ore efficient( *hen cases present on call< use the+ asopportunities to revie# and utilie #hat youDve learned< as this #ill help you consolidatekno#ledge on the +anage+ent of these conditions(

Beyond that< having a consistent pace in daily reading each night helps to cover all necessary+aterial( !o not neglect the su'specialty topics as these can all 'e testa'le on the oral ea+ as#ell as the &BME @see J*hat is the ea+ for+atIK 'elo#( This +aterial is 'est covered 'ygoing to all the acade+ic half day lectures< and revie#ing those presentations throughout thecourse of the rotation and 'efore the ea+s(

)0) The CLE8SH74 GU7!E ; 8otations



The su'specialty #eeks tend to present +ore availa'le ti+e and less fatigue usually than thegeneral surgery #eeks< and thus it is reco++ended one use this ti+e #isely to revie# and studyfor the ea+s( Motivation to do this is harder to find if one is starting #ith the su'specialty#eeks 'efore general surgery< 'ut students #ill definitely appreciate it later if they stay on top oftheir reading early.

Me+ora'le Mo+ents

!uring +y pediatric general surgery selective< #e had a child co+ein #ith a volvulus that needed to 'e corrected right a#ay( 7 got toscru' in as second?assist for the really interesting surgery( The

'o#el is actually pulled out of the a'do+inal cavity< unt#isted< andthen replaced #ith the s+all 'o#el on the patientDs right and thelarge 'o#el on the left to prevent future pro'le+s( Since theappendi #ould end up on the left side of the 'ody< #hich< if it#ere to 'eco+e infected< #ould present atypically for appendicitisand could easily 'e +issed until it #as too late< an appendecto+y isperfor+ed as #ell( The fello# had >ust tied off the appendi at its

'ase< and the surgeon put the +etal dish #ith the scalpel in front of

+e( J*ould you like to do the honoursIK

7 looked at hi+ 'lankly< not Fuite getting #hat he +eant< since +yusual >o' #as li+ited to holding retractors and occasional suturing(J*hat do you +eanIK

J-ou can cut the appendi off if you #ant(K

My eyes lit up and 7 eagerly took the scalpel( 7 cut through the#or+y piece of 'o#el >ust a'ove the tie the fello# had put on< anddropped the no#?detached appendi into the speci+en container( 7couldnDt stop s+iling( 7 #as a third year +edical student and 7 had

>ust re+oved an appendi( Ho# fantastic is thatI.I.I


*e all have healthy ho''ies andactivities that keep us centered and

grounded( Music< dance< yoga< art#orkare >ust so+e ea+ples( %or +e< athletics

is a +ust in +y life and is one activitythat 7 #as not #illing to give up

regardless of ho# cray +y schedule

#as( no#ing that spending a little ti+ekeeping active every day #as notsacrificing study ti+e 'ut rather a tool to

help +e 'e 'alanced and +oreproductive allo#ed +e to a little

so+ething every day guilt free( Even oncall shifts a good stretch or #alk aroundthe hospital #hen 7 #asnDt 'usy helped

+e 'e successful.

GE 7&G 47M4E!" *HA HE !$C $8S E&! $ AS

Ti+e in the $8 is a pri+e chance for surgeons to ask students Fuestions< and these are generallycentered around the current surgical case( Epect to 'e asked Fuestions such as presentation anddifferential diagnosis of the conditiondisease< #hen surgery is indicated and #hat type ofsurgery< post?surgical +anage+ent< and of course< surgical anato+y in #hich youDll 'e asked to

identify structures that can 'e seen @and so+eti+es those that canDt. This +eans itDs a s+art ideato pre?e+ptively revie# oneDs general anato+y notes for a given 'ody cavity @usuallya'do+inalpelvic in general surgery cases prior to a day in the $8< including na+es of 'loodvessels< nerves< and other structures( Students should check #ith the $8 'ooking desk the day 'efore their scheduled $8 day to find out #hat surgeries are on the slate for their surgeon< inorder to adeFuately prepare 'eforehand and i+press their attending(

)0/ The CLE8SH74 GU7!E ; 8otations



As for ti+e outside the $8< fe# Fuestions are generally asked #hile rounding due to ti+econstraints< 'ut do epect to 'e asked Fuestions during the clinics as #ell as #hile on call( These#ill again 'e centered around patients and relate to diagnosis and +anage+ent of surgicalconditions( *hile on call< the key Fuestion #ill al#ays 'e to ans#er Jdoes this person needsurgery< is this no# i++ediately or later< and #hyIK Thus itDs 'eneficial to study co++onpresentations of conditions prior to call shifts(

Although residents are generally very happy to teach students any chance that arises< surgery is

still a 'usy service< and often surgeons +ay not 'e used to finding the ti+e to ask studentsFuestions or teach( They +ay also 'e used to talking a'out casual life topics #ith other staffduring $8 ti+e< as +any are skilled enough to essentially run on autopilot during surgeries and+ultitask their attention( As such< students often need to 'e proactive and ask Fuestions to thesurgeon in order to spark conversation and learn around a patient case( &ot doing so +ay resultin a dissatisfying surgery rotation eperience< as #ell as possi'ly so+e silent< a#k#ard clinic$8ti+e.

HA&!S $&" 48$CE!U8ES -$U GE $ !$ 7& H7S 8$ A 7$&

Most co++only students #ill get the opportunity to perfor+ si+ple procedures in the $8< suchas helping to close incisions at the end of surgeries #hen they are scru''ed in( Surgeons typicallyleave the last layer or t#o of tissue for the surgical resident to suture up and students can 'eepected to help the+ cut< or at ti+es even tie their o#n< sutures( Staple closures and dressingscan 'e co+pleted 'y students as #ell( *ith patients on the #ard< students +ay get theopportunity to check incisions and re+ove staples if there is an etended stay post?operatively($ther procedures that students +ay have the opportunity to co+plete include nasogastric @&G

tu'e insertions< colosto+y 'ag changescleanings< foley or 73 insertions< and any othersu'specialty specific procedures(


L7EL- GE !U87& G H7S 8$ A 7$&

There is a list of patient encounter o'>ectives availa'le on Medicol and the $ne0: logging pagefor surgery< #hich includes conditions #hich students should have an opportunity to 'e involvedin the assess+ent of< or at least learn an approach to( These can vary fro+ the co++on such asappendicitis< s+all 'o#el o'struction< or gallstones< to the +ore uniFue conditions found in thevarious su'specialties( 8egardless of the condition< ho#ever< any student should have littletrou'le covering the +a>ority of these patient encounter o'>ectives through their general surgery+onth< and any +issing areas can 'e taught 'y residents on reFuest< especially during do#nti+e#hile on call( =ust re+e+'er to log encounters into $ne0: every #eek at +ini+u+< as anylonger duration #ill result in one forgetting #hat one has seen(

)0, The CLE8SH74 GU7!E ; 8otations




A good portion of learning #ill co+e fro+ on?call eperience and teaching opportunities #ithresidents and attendings( Ho#ever< there is undou'tedly a need to study on your o#n in additionto these learning opportunities if one is to pass the ea+s( Most students pick a study resource 'ased on personal preference< and in the end the choices are eFuivalent as long as it is +atched tooneDs learning style< and the student actually co+pletes reading the resource(

7t is highly reco++ended to pace the studying right fro+ the start< rather than leaving it to thelast fe# #eeks to cra+( $ne should especially utilie their +onth of selectives as study ti+e(!uring the last / #eeks< a 'rief overall revie# of co++on surgical conditions helps refresh and

consolidate kno#ledge( A fe# days 'efore the ea+< atte+pt nu+erous &BME style practiceFuestions in order to 'e accusto+ed to the +indset of reading and ans#ering Fuestions Fuickly<and the level of understanding reFuired 'y the ea+(

And for the ,rd ti+e< revie# the acade+ic half?day lectures. There are / of the+< true< 'ut theycover #hat one needs to kno# for the oral ea+ and they help for the Fuestions related tosu'specialties on the &BME(

HE %7&AL B$SS" E&! $% 8$ A 7$& EAMS

The surgery ea+s consist of an &BME and oral case scenarios ea+< 'oth occurring during thelast #eek of the rotation( There is no $SCE ea+(

The &BME ea+ is a standard )66 +ultiple choice Fuestion ea+ that is provided 'y theA+erican &ational Board of Medical Ea+iners to 'e co+pleted in a span of / hours :6+inutes( 16 or greater is reFuired to pass the ea+( Each Fuestion typically consists of apatient vignette illustrating a presenting case #ith associated investigations and results< follo#ed 'y a clinical Fuestion #ith @usually : +ultiple choice selections( As the ea+ is A+erican< thela' values #ill also 'e in US units< 'ut a reference sheet of nor+al la' values #ith 'oth US and S7@international units is provided and students soon 'eco+e accusto+ed to recogniing #hen a la'value is significantly a'nor+al( The Fuestions are nota'ly longer reads than previouslyencountered MC Fuestions fro+ )st and /nd year +edicine ea+s and have 'een kno#n tocontain etraneous or ecessive details not reFuired to ans#er the Fuestion( As such< it isreco++ended that ea+inees first gli+pse #hat the Fuestion is asking< then read Fuickly throughthe vignette 'efore providing oneDs 'est ans#er and +oving on to the net Fuestion( $ne can runout of ti+e if one +eticulously reads and over?analyes each and every Fuestion.

Although the +ain focus of the &BME ea+ is surgery< +any Fuestions do reFuire a 'aseline

kno#ledge of internal +edicine principles as they ask a'out pre? and post?operative care< thus ifone has gone through their internal rotation< it is helpful for this ea+( 7f surgery is oneDs firstrotation< it +ay 'e 'eneficial to put so+e ti+e into a 'rief overvie# of co++on internal+edicine inpatient issues< such as cardiac< respiratory< or G7 pro'le+s( $ne should also payattention to any chapters regarding pre? and post?operative +anage+ent in their revie# 'ooks< orin the general surgery tet'ook provided 'y the depart+ent at the start of the rotation(




The oral ea+ consists of four /6?+inute stations in #hich a surgeon #ill present a case and askFuestions 'ased off this regarding approach to history< physical< differential diagnosis< and+anage+ent( $ne station #ill 'e on general surgery< and the other , #ill 'e selectedsu'specialties( 7n general< at least one station #ill 'e fro+ one of the selectives the studenteperienced( There are +ethods in #hich one can predict #hich stations can 'e epected< 'asedon the co++on shared selectives of students passing through each track as listed on the studentea+ schedule< 'ut this +ay not al#ays 'e accurate(

8espect the oral ea+( 7t can 'e very difficult if one does not adeFuately prepare( 4repare forthis ea+ through thorough revie# of the acade+ic half?day lectures< #hich present +anage+entapproaches to co++only encountered conditions in each su'specialty @e( AAA in vascular<oncologic e+ergencies in rad onc< hand fractures in plastics< etc(( 7f one co++its a reasona'lea+ount of ti+e into revie#ing for the oral ea+< one #ill find the cases and Fuestions to 'e fairand logical< or at the very least that one #ill have a guess as to #hat the diagnosis is and canans#er accordingly(

HE MA4" S7 E S4EC7%7CS %$8 HE 8$ A 7$&

As there are nu+erous sites in #hich one can co+plete their general surgery +onth and even+ore for the different su'specialties( 7t is i+practical to cover specifics for all sites here( 4leaserefer to the hospital site guide chapter for details regarding general infor+ation(

Each site #ill have a different +eeting location on the first day< as deter+ined 'y either the chiefresident or staff supervisor(

Teaching generally consists of on?call infor+al teaching fro+ residents< teaching duringoutpatient clinics< and the acade+ic half?days @no noon rounds in surgery unlike in internal+edicine< +eaning fe#er free lunches.(

3GH has su'divided general surgery tea+s @ie( initial intake tea+< oncology surgery tea+< etcthat each have different patient 'ases< schedules< and #orkloads( Students are assigned to onetea+ for the entire +onth(

Most sites are generally eFuivalent #hen it co+es to surgical eperience< although so+e studentshave co++ented that 3GH +ay have less $8 ti+e availa'le for student involve+ent due to +oresurgical residents and higher surgical consult volu+e fro+ e+ergency co+pared to other sites(

The patients that present to each site tend to 'e generally si+ilar< as there are only a fe# co++onissues reFuiring surgical consultations fro+ the e+ergency(

)0: The CLE8SH74 GU7!E ; 8otations



HE L7S " )6 H7&GS $ &$*

: co++on general

surgery conditions to

kno# a'out"

: things you can#ill do #hile in the $8 for surgeries

as a +edical student"

)( appendicitis )( retract( !o this #ell< or you #onDt 'e asked to do anything els#hile in the $8(((

/( s+all 'o#el o'struction /( suturing @s+all laparoscopic incisions or stapling( 4racticeyour ) handed ties in advance.

,( gallstones ,( ans#er pagers( 8esidents< and even attendings< #ill reallyappreciate you for this(

0( hernias 0( #rite the post?op note( 8evie# this #ith the resident afteryouDve #ritten it(

:( any a'do+inal +alignancy :( laparoscopic ca+era @if no residents around( 4ractice keepinyour hands steady for this one(


The surgery rotation provides the +ost operative eperience students #ill have all year long andshould 'e fully taken advantage of( The opportunities to see and do these procedures #illgradually d#indle in oneDs +edical career< unless they take the long< tortuous @or so+eti+estorturous path of surgery. So >u+p at the chance to hold that retractor< to follo# that suture line<and yes< even to transfer that patient post?surgery< as you +ight not get to do it again later on(Ad+ittedly< one can Fuickly 'eco+e 'ored in general surgery( $nce youDve seen one

appendecto+y< youDve really seen the+ all @presu+ing youDve seen 'oth a laparoscopic and an

open one( By the ,rd iteration< one starts to feel like they can do the surgery the+selves @notreco++ended< no +atter ho# confident you feel( Ho#ever< iitDs precisely in this fa+iliarity thatsurgeons thrive in< as the +ore routine and straightfor#ard an operation starts to 'e for theoperator< the less likely that surgical co+plications arise fro+ ineperience(

!onDt 'e that student #ho avoids the $8 like the plague< no +atter ho# distasteful you findsurgery to 'e( -ouDll inevita'ly have to 'e scru''ed in at so+e point< and unless youDre keen<interested< and relia'le< youDll never get 'eyond the step #here you hold the retractor for an hourstraight( ThereDs certainly lots to see< lots to get your hands into @not all of it pleasant< and lotsto learn( !o also take advantage of your selectives< as again< those are opportunities that +ay

never arise again in oneDs +edical career(




Early @a(k(a( earliest +orning rounds can 'e grueling< especially if youDre in track A or B #ithsurgery in the dark cold +onths of #inter< 'ut luckily< surgeons #rite @and epect students to+i+ic the +ost 'rief< succinct progress notes youDll ever see( $ne particular attendingDs progressnote consists of #riting Jdoing #ellK on the chart< follo#ed 'y a sFuiggly line @his signature(Although not so+ething students could ever get a#ay #ith< that doesnDt +ean our notes canDt 'e

efficient either( J!id you pee< did you poo< did you eat< did you pass gas< did you get up and#alk< yesI Good( !oes it hurt or 'leed any#here< do you have a fever< noI $k see youto+orro#(K





E+ergency

*ritten 'y Leslie Anderson and Andy Chen< M! /6),


HE B7G 47C U8E" 7& 8$!UC 7$&

E+ergency is a 0?#eek rotation #hich the +a>ority of students a'solutely love( Students #ill seea #ide variety of patients< get the opportunity to do procedures such as suturing< and evenpossi'ly 'e involved in so+e life?and?death situations( $ne +ight even help to revive so+eone#ith C48.

The field of e+ergency spans a 'road scope of kno#ledge and skills and reFuires certainpersonality characteristics such as the a'ility to +ultitask and think or react Fuickly( Althoughe+ergency depart+ent physicians @E!4s< like fa+ily doctors< +ust understand a little a'out a

lot in order to kno# ho# to treat and +anage a ne# patient< they +ust also learn a veryspecialied skill set related to acute resuscitation< critical care< and disaster +anage+ent(E+ergency is a specialty in #hich triaging patients 'ased on urgency is turned into an art< and

directly resolving or redirecting pro'le+s 'eco+es second nature( There are fe# things that canco+e through the doors that an E!4 #ould not kno# ho# to handle< or even +ake the+nervous.


$n average< +ost students #ill 'e scheduled for )5?)2 shifts during the 0 #eeks< and each shift#ill usually 'e 2 to )6 hours long< depending on the hospital site< type and ti+e of the shift @e(

overnight shifts +ay 'e shorter than dayti+e shifts< acute care vs fast track< etc( The ti+e of dayyou start #ork #ill vary as #ell< #ith so+e shifts 'eginning early in the +orning #hile others arein the afternoon< and +ost people #ill #ork at least a fe# overnight shifts( 7n general< studentschedules #ill group a series of day shifts together< and a series of night shifts together< in order totry and provide so+e sort of regular sleep cycle for students( Ho#ever< students shouldnDt 'esurprised if they find the+selves #orking 0 days follo#ed 'y , nights #ith only a single day off in 'et#een( There are also acade+ic half days on Thursdays that students #ill attend< and along#ith #eekend shifts< students should epect to have roughly 1?5 days off only during the 0 #eeks(!espite the 'usy schedule< there is lots to see and do and thus +any students donDt find

the+selves 'ored or over#orked(


There is no traditional call shifts in e+ergency< as students are scheduled for shifts @so+e of#hich +ay 'e overnight< and thus the schedule is pretty straightfor#ard(




HE GEA8" *HA $ B87&G 9 CA88-

Students should 'ring their stethoscope< a pen< and snacks( E+phasis on the snacks( E+ergencycan 'e very hectic and 'usy< and it +ay 'e difficult finding ti+e to stop and eat a proper +eal(Hence< anything one can shove in their pocket 'eco+es critical to surviving the shift( $ther

ite+s that co+e in handy includes a penlight< a s+all note'ook to >ot etra notes in< and a pocketdrug reference as #ell(


4A 7E& S A&! $ HE8 7&%$

Most of the ti+e students #ill #rite directly in the patientDs chart< 'ut so+e people prefer havinga note'ook handy to >ot do#n #hat theyDve seen for logging and studying purposes( =ust ensureone doesnDt let this cause the+ to slo# their #ork pace do#n(


Students #ill 'e provided #ith a core content +anual on Medicol that they are epected to read

through and for +ost people< this is sufficient( The other reference that is highly reco++ended isToronto &otes( !epending on the person< &MS E+ergency or 4ocket Medicine #ill also #ork< 'ut often there #onDt 'e sufficient ti+e or energy to read too +any in?depth 'ooks(

Me+ora'le Mo+ents

$ne of the least re#arding realities of +edicine is the inevita'leencounter #ith death( 7 #ill al#ays re+e+'er the first patient 7 sa# #ho

died( 7t #as a cold !ece+'er night #hen #e 'rought her to the $8 #itha gro#ing uterine cancer( 7t had 'een a frustrating #eek gettingeverything ready< one of the greatest set'acks 'eing her refusal for 'loodproducts( Understanding the risks involved in the surgery< she consentedto the surgery any#ay( 7 #ill never forget +y attendingQs change in facialepression #hen he sa# the fria'le cancer< 'leeding profusely< +oreadvanced than #e had thought( *ith an intraoperative he+oglo'in of)< #e kne# her chances #ere gri+( 7 re+e+'er spending a fe#+o+ents to say good'ye as she lay lifeless in the recovery area( 7 reflecton her case often< kno#ing that she suffered fro+ depression< loneliness<and a lack of social supports( $ne thing 7 have learned ? +ake every#ord count< 'ecause it +ay 'e the last #ords that they hear(

?=oseph Leung< M!/6),


8aising a fa+ily or +aintaining arelationship #hile 'eing at the 'eck andcall of your seniors is not easy( Ho#ever

'y +aking fa+ily and relationships apriority< 7 #as a'le to find ti+e(

So+eti+es< this +eant 'eing inflei'leand telling your supervisor that #hile

you #ould love to stay and do thedisi+paction< you have a play date #ith

your kids( At other ti+es< this +eans 'eing flei'le and taking advantage of

opportunities that arise( By keepingfa+ily and relationships at the forefront

of your +ind< achieving a healthy 'alance during clerkship is possi'le.





8$ A 7$&

Students should read around their patients and ensure they revie# 'oth the co++onlyencountered pro'le+s @e( angina< a'do+inal pain< +igraines< decreased level of consciousnessetc(< as #ell as the life?threatening things that should never 'e +issed @e( +eningitis< sepsis<STEM7< AAA etc(( There #ill 'e an acade+ic half day each #eek and these sessions cover+any crucial topics< thus they are #orth going to(

GE 7&G 47M4E!" *HA HE !$C $8S E&! $ AS

Most co++only students #ill 'e asked for their differential diagnosis< and #hat investigationsshould 'e ordered( They +ay also ask students to interpret ?rays and la' results< and #ill epecta discussion regarding the +anage+ent plan( Anything is fair ga+e in e+ergency.

HA&!S $&" 48$CE!U8ES -$U GE $ !$ 7& H7S 8$ A 7$&

The range of #hat students actually end up doing #ill vary #idely depending on the site and

#hich patients happen to co+e in during oneDs shifts< 'ut students can epect the chance to dosuturing< fracturedislocation reductions 9 casting< 73s @>ust ask the nurses< and possi'ly ABGs<intu'ations< and C48(


L7EL- GE !U87& G H7S 8$ A 7$&

Students #ill see +ost of the e+ergency reFuire+ents and #ill also likely check off several of the+ust?sees for internal +edicine< psychiatry< and orthopedics< given the #ide variety of conditionsthat can #alk through the door(


Students should ensure they read the +any ecellent files and resources availa'le to the+ toprepare for the ea+ @check #ith +ore senior +edical students regarding #hich eact files toread< and #here to find the+( The core content +anual is also +andatory reading during therotation< and provides +uch useful infor+ation for students to read and learn fro+( Althoughthis rotation can 'e 'usy< try to find ti+e at ho+e to study< as there #ill likely not 'e any ti+e tostudy #hile on shift(

HE %7&AL B$SS" E&! $% 8$ A 7$& EAMS

The end?of?rotation ea+ is a co+puteried :6 Fuestion +ultiple choice ea+< to 'e taken at theLSC +ultipurpose la' at UBC on the last %riday of the rotation( 7f students have read throughall of the reFuired and reco++ended +aterial< they should have no pro'le+s passing the ea+(

):6 The CLE8SH74 GU7!E ; 8otations



HE MA4" S7 E S4EC7%7CS %$8 HE 8$ A 7$&

To find out #here to go on the first day< CHEC -$U8 EMA7L for a +essage fro+ the depart+ent( Listed is #herestudents have +et on day one in the past(

S it e H er e i s # he re st ud en ts have +e t o n d ay

one in the past"

*here can 7 store +y

'elongingsI

*hat kind of teaching or acade+ic sessions

are there at this siteI

3GH -ou #ill have an orientation on the first day andinstructions #ill 'e e?+ailed to you( %or each

shift< you #ill either go to the acute side or thetreat+ent side @if youDre on a float shift< you starton the acute side and find the doctor starting atthe sa+e ti+e you are( -ou #ill also #ork t#oshifts at UBC Hospital< and you >ust sho# up andask the nurse at the desk #ho youDll 'e #orking#ith(

&o lockers are availa'le< 'ut youcan leave your stuff in the E8

staff roo+ @>ust donDt leaveanything too valua'le.

The acade+ic half days are held at 3GH onThursdays( -ou also #ork one?on?one #ith your

preceptor and +any of the+ are ecellent teachers(

8CH

Eagle

8idge

8eport to the E+ergency 4hysician< #ith #ho+you are scheduled to #ork< at the start of the shiftand they #ill orient you to the layout and to yourclinical role in the !epart+ent( 7t is also veryi+portant that you report to Sherry Hu'ick inMedical Education on your first day to co+pleteso+e +ini+al paper#ork and to o'tain a photo7!< along #ith your orientation +aterial(

Lockers are availa'le in theresidents lounge in the 'ase+ent(

Al+ost all E+ergency !epart+ent teaching #ill 'edone around individual cases that you see( Try tothink of a focused o'>ective or t#o to 'ring up #ithyour attending during each shift to ensure that youaddress all of the learning o'>ectives during yourrotation( Clearly not every learner #ill do everyprocedure listed< 'ut you can at least talk a'out eacho'>ective over the course of your rotation( $urphilosophy is that house staff are here for educationand eperience< not strictly for #ork( *e all en>oyteaching< 'ut patient care is our pri+ary role( Atti+es #e cannot teach as +uch as #e #ould like to(!espite these practical real #orld li+itations< thereis still a lot to learn in this !epart+ent(

There are regular teaching rounds at 8CH posted ona green flyer in the E4Qs office and you are #elco+eto attend any of these #hen not on duty( 7f the!epart+ent is very Fuiet and there is a relevanttopic at noon rounds you could ask the E4 you are#orking #ith if you +ay attend(



S it e H er e i s # he re st ud en ts have +e t o n d ay

one in the past"


'elongingsI

*hat kind of teaching or acade+ic sessions

are there at this siteI

S4 H -ou #ill receive an e+ail 'efore your rotationindicating #here to go on day one(

There is a E! doctorDs loungeavaila'le to put things in< 'utstudents #ill need their passcardto access this roo+(Alternatively< students can alsodrop their stuff off in the internal+edicine consult service roo+(

*hile the acade+ic half days are i+portant< a largea+ount of learning is done on site( Make sure to 'einFuisitive as the staff that you #ork #ith are very#illing to teach(

SM H The coordinator #ill +eet #ith ne# inco+ing

students 'et#een the hours of 650:hrs and)066hrs to provide lockers< login infor+ation<hospital 7! @still +ust #ear UBC 7! and parkinginfor+ation(Meet the site leader or the designate at triage inthe E!( -ou #ill 'e given the orientation ti+e#hen you receive your schedule( Most of the ti+eyou #ill do a shift after your orientation(Announce yourself to the triage 8&< let the+kno# #ho+ you are +eeting and they #ill 'ecalled(

There are lockers availa'le for

studentsD use on the ,rd floor of% 'uilding( -ou +ay use youro#n locksR ho#ever< you +ust 'ea#are of the follo#ing" if a code 'lack is called< you +ust re+oveyour lock Fuickly other#ise +ay 'e necessary to cut off( @locks areavaila'le fro+ +edicaleducation

The on?site teaching is clinically 'ased and you have

direct access to the staff for all your shifts( Most ofthe teaching #ill 'e delivered as YpearlsY @do notepect any didactic sit do#n session( Ask lots ofFuestions< the staff love to teach( The acade+icsessions are at 3GH on Thursdays(

8ich+

on d

-ou #ill +eet a e+erg doctor 'y the nursingstation in the acute care area( This doctor #illgive you a tour of the facility and let you kno##here to go net

There is a locker roo+ #ith s+alllockers availa'le for students(There is also a staff lounge #ith afridge and +icro#ave

There is no for+al teaching 'ut physicians are verykeen to teach around cases

4eace

Arch

4ark in the lot to the #est of e+erg< head intoe+ergency and ask a nurse for the doctor(

There are lockers for +edstudents in the e+ergencydepart+ent(

ThereDs only infor+al teaching during your shiftsaround cases( &ot a pi+p heavy location

Mount

St(

=oseph

=ust sho# up in the E8 and ask the nurse #ho theE8 doc is( 7tQs super s+all so there #ill 'e no #ay of getting lost(

!octorQs roo+ in the 'ack( =ust #hatever you go through #ith your preceptors(Good hands on s+all procedures @e(g( fracturereduction< he+ato+a 'locks< casting< lacerationsetc(( Also< each E8 doc #ill have differentpreference for ho# you present( 7t can 'e useful to >ot do#n each docQs preference 'ecause so+e arevery different in style(



Si te 7s th i s a good si te for so+eone interested in thi s

specialtyI

*hat are co++on pro'le+s patients at

this site haveI

*hat is the call

schedule likeI

3GH -es( -ou are one?on?one #ith an e+erg physician and you canget a lot out of the rotation if you sho# interest

A'do pain< chest pain< trau+a( -ou #onDt seeany children @since BCCH is so close andvery fe# pregnant #o+en @sa+e reason #ithBC*H(

There arenDt full callshifts< 'ut students #illtypically have , overnightshifts fro+ +idnight to2a+< and : late nightshifts that end 'et#een /?,a+(

S4 H -es< the E! is 'usy and you #ill encounter a large variety of

cases(

There are +any 73!U and M8SAX cases that

arrive at S4H< +ore than other hospitals(8CH

Eagle

8idge

*e are one the 'usiest e+ergency depart+ents in BC and inCanada< seeing a'out 15<666 patients per year at the 8CH site(*e have /: full?ti+e specialty trained E+ergency 4hysicians#ho spend /, of their ti+e at 8CH and ), of their ti+e atEagle 8idge Hospital @E8H( The nursing staff are veryeperienced and are a valua'le resource< if you listen to #hatthey have to say( *e have L4&Qs and orderlies #ho do all ourcasting and splinting #ho #ill 'e happy to teach you theseskills< if you ask(

*e see a +iture of adult and pediatricpatients(

8otation schedule" -ourrotation schedule should 'e availa'le a fe# #eeks 'efore your rotation is tostart( -ou #ill #orkapproi+ately 0?: shiftsper #eekR a +iture ofdays< evenings< nightsand #eekends(

SM H This is an ecellent site for so+eone #ho #ants to eperience avery 'usy full service E! and #ants to see and learn as +uch aspossi'le( The great advantage of our site is that there is never+ore than one learner per day in a section of the E!(

SMH has the 'usiest E! in BC( *e see a #iderange of patients fro+ pediatric to geriatric#ith pro'le+s spanning all specialties( Theonly facet that is not covered #ell is Y'igYtrau+a( *e do see Y+inorY trau+a @#hich can

so+eti+es turn out to 'e +a>or 'ut the 8oyalColu+'ian Hospital is )6 +inutes drive a#ayand they are the designated trau+a centre for%raser Health(

8otation schedule" Thereare seventeen 2 to hourshifts during the rotation(Before the rotation startsyou #ill 'e given an

opportunity to tell us ofany reFuests and theseare al+ost al#ayshonored(

8ich+

on d

-es( -ou #ill 'e the only +edical student at the hospital for theentire +onth +eaning that you have priority access.

&o trau+a and fe# serious acute caresituations( The +a>ority of cases are to#ardsthe fa+ily practice end of the spectru+@gastroenteritis< strainssprainsfractures<lacerations etc



Si te 7s th i s a good si te for so+eone interested in thi s

specialtyI

*hat are co++on pro'le+s patients at

this site haveI

*hat is the call

schedule likeI

4eace

Arch

Good preceptors< #ho are happy to have you there< lo#pressure< good +i of pathology and representative ofco++unity E!s( All docs are CC%4 so +ight not 'e the 'estfor getting 8oyal College reference letters(

Mi of elderly and young to +iddle agedadults plus children( Chest pain< #eakness<lots of ortho< gastro( -ou are given a lot ofindependence in general(

Mount

St(

=oseph

&o( This has no night shifts and the volu+e is very s+all( Thedoctors are great to #ork #ith 'ut +ost have little pull in theselection process at UBC( 7tQs great if you are not interested inE8 though< and donDt #ant to spend ti+e overnight at the

hospital(

A'do+inal pain< rule out M7Qs< geriatric E8<psyc stuff< no trau+a(

&o call @in the E8



HE L7S " )6 H7&GS $ &$*

: conditions not to +iss diagnosing : procedures to read on in advance< as you #ill

likely do the+ in the E!

)( M7

Although the classical description of heavy pressure chest

paindisco+fort #ith radiating pain to the left neck and ar+is hard to +iss< M7s donDt al#ays present this #ay( 7nstead<one +ight see pains to the 'ack or a'do+en< and often#o+en present differently than +en typically do( 7f thereDsever a suspicion of an M7< itDs #orth getting an ECG andtroponins to 'e sure(

)( Suturing

Lacerations< lacerations< lacerations( 7n no other rotation

#ill students get +ore opportunity to practice their suturingskills @surgery inclusive( Luckily< students usually #onDthave an attendingresident #atching over their shoulder<presu+ing they de+onstrate they are fa+iliar andco+petent #ith suturing techniFues @having pre?read andall.(

/( Stroke

A he+orrhagic stroke can 'e rapidly life?threatening< andalso 'e contraindicated for certain stroke treat+entprotocols( 7n any case of acute neurological or 'ehaviouraldeficitchange< especially in the elderly< one shouldinvestigate to rule stroke out urgently(

/( %racture reduction and casting

ThereDs undou'tedly going to 'e +ore than ) 'roken 'oneco+ing through the doors< and one shouldnDt 'e surprised tosee +ultiple on a single shift( Although so+e fractures aretoo co+plicated to resolve in the E! and reFuire anorthopedic consult< +any others are si+ple transversefractures that can 'e reduced and casted 'y E! doctors @and

students(,( AAA

There is a vast differential for a'do+inal pain< and a+ongthe+ includes a'do+inal aortic aneurys+s< #hich poses avery high +ortality rate in cases of rupture( 4atients #ithco+plaints of pain in the a'do+en should al#ays 'epalpated for a pulsatile +ass< and if coupled #ith rapidlydecreasing 'lood pressure< should 'e assu+ed to 'e AAAuntil it is other#ise ruled out(

,( !rainingaspirating fluidpus'lood filled

cavities

7f thereDs a 'ody part one can think of< thereDs a #ay to fill it#ith so+e sort of fluid< 'e it pus< 'lood< +ucus or any other 'ody secretion( %ortunately< thereDs also al+ost al#ays a#ay to stick a needle in it and drain the cavity( 7f aninfection is suspected< donDt forget to save the aspirate forculture< and not >ust instinctively toss the entire needle in thesafety 'in.



0( C?spine fracturein>ury

*hether itDs a high speed +otor vehicle collision< high levelfall< or a i+pacting sport in>ury< one +ust al#ays presu+ethere is a c?spine in>ury and protect the neck until it is ruledout< either through ?ray or 'ased on clinical findings( Evenif the patient is a'le to +ove their head on their o#n< thisdoes not guarantee no occult fracture has occurred(

0( 8esuscitation"

C48< air#ay +anage+ent< and fluid replace+ent are allprocedures that reFuire Fuick thinking and efficient action<and students +ay 'e called upon to contri'ute in various#ays( 7t helps to not 'e caught off?guard like a deer in theheadlights(

:( G7 Bleed

So+eti+es innocuous< so+eti+es #orriso+e< so+eti+esdire< depending on the a+ount< the ti+ing< and the colour(Many patients can have chronic occult G7 'leeding< #hich#arrants further investigations< 'ut not on an urgent 'asis(Ho#ever< it is those #hich have a severe a+ount of 'rightred 'lood that persists that reFuires an i++ediateconsultation fro+ the G7 service< especially if the patient ison a 'lood thinner(

:( !isi+paction"

Although not co++only seen< it does co+e up< and isreno#ned for 'eing one of the dirtiest procedures in the fieldof e+ergency( *hether one #ants to encounter the need toperfor+ this procedure or not highly depends on if they had >ust eaten(((




E+ergency isnDt si+ply a triage and referral service< redirecting any and all co+ers to theappropriate specialist( They are in the+selves a specialist of +anaging acute pro'le+s< ensuringappropriate treat+ent or consultation is provided for all diseases and conditions< and of course<saving peopleDs lives in life?threatening e+ergencies( As a rotation< you #ill find a large a+ount

of en>oy+ent< kno#ledge< and satisfaction in co+pleting each shift< despite the longer hours ofnon?stop #ork @ti+e passes faster #hen thereDs stuff to do.( Certainly there #ill 'e +any casesthat one has no idea ho# to diagnose or treat< 'ut it is in these #here the +ost learning is to 'egained( %urther+ore< youDll develop your skills in +ultitasking like never 'efore< and youDll 'esurprised ho# +uch your short?ter+ +e+ory can store #hen you need to track 0 patients at thesa+e ti+e. *hether you have this rotation at the 'eginning< +iddle or end of your year< thereDs+uch to see< do< and like.





Anesthesia

*ritten 'y Serge Makarenko< M! /6),

HE B7G 47C U8E" 7& 8$!UC 7$&

Anesthesia is a / #eek long rotation coupled #ith orthopedics< and is generally a relaed anden>oya'le learning eperience( The discipline is focused on the principles of physiology andphar+acology< and involves a large hands?on co+ponent through the ad+inistration of 73 andinhalational anesthetics and other drugs( By the end of the rotation< students should epect tohave had so+e practice and eperience #ith tracheal intu'ations< laryngeal +ask air#ayinsertions< and 73 place+ents( Students should also 'eco+e fa+iliar #ith the use of variousinduction agents and analgesics(


The +a>ority of the / #eeks of anesthesia #ill 'e at the assigned hospital site< #ith the eceptionof ) day at BC*H and ) day at BCCH for +aternity and pediatric anesthesia< respectively(Students +ay also spend ) day on the acute pain service or anesthesia consult service at theirlocal site( There are occasional lunchti+e se+inarsteaching sessions #ith residents< 'ut theseare site?specific( Best of all< there are no +orning rounds or call for anesthesia.

The typical day usually spans fro+ 5",6 to anyti+e in the afternoon< depending on the $8 startti+e and ho# +any surgeries are on the slate( Students typically are assigned a specific $8 oranesthesiologist for the day< and are epected to sho# up in the +orning early< check?in #ith theanesthesiologist< and usually see the first patient in the pre?op #aiting roo+ so that the doctor has

ti+e to set?up their anesthesiology cart(

Throughout the day students #ill 'e participating in the pre?op anesthetic historyphysical ea+@either perfor+ing< or assisting< anesthetic induction in the $8 @see procedures section 'elo#<+onitoring throughout the case @and getting pi+ped at the sa+e ti+e< and then etu'ation andpost?operative assess+ent and care(

$nce the patient is asleep during the operation< students #ill have lots of ti+e for one?on?oneteaching #ith their attending and often #ill 'e allo#ed to go for a coffee or study 'reak #hile thecase is happening( !epending on the length of the surgery< this 'reak can 'e any#here fro+ ):

+inutes to an hour.

Most $8 slates are usually scheduled until , to 0 p+ in the afternoon< 'ut often the supervisinganesthesiologists #ill let the student go early after the last patient of the day has 'een induced< asthere is less learning opportunities re+aining after that< and there has already 'een plenty ofteaching 'y that point of the day already(





As previously stated< there are no call shifts scheduled for this rotation( Ho#ever< for studentsparticularly keen or interested in anesthesiology< it +ay 'e possi'le to talk to the sitedirectorsupervisor and arrange for additional or replace+ent shifts to span the overnight period(

HE GEA8" *HA $ B87&G 9 CA88-

Stethoscope< a notepad or scrap paper for so+e note?taking< and a pen( !onDt 'ring a 'ag intothe $8 as there usually #onDt 'e a place to put it< and there #ould also 'e concerns regardingsterility and sanitation( Also 'ring in so+e kind of reading +aterial< either in paper or electronicfor+at< as there +ay 'e lots of do#nti+e for reading on the co+puters in the $8( %inally< donDtforget to carry all evaluation for+s and a daily log. After each day< students #ill need theiranesthesiologist to fill out an evaluation< and also sign a schedule log< as these #ill need to 'esu'+itted at the end of the rotation to pass.


4A 7E& S A&! $ HE8 7&%$

4en and paper al#ays #orks #ell< or if one prefers< #ith a s+artphone @'ut 'e careful #ith this<as so+eti+es staffpatients can assu+e one is teting #hen one is actually taking notes( *ritedo#n patientscases seen through the day< 'ut in general there isnDt +uch infor+ation that needsto 'e tracked( Take the anesthesia consult sheet after assessing a patient in pre?op holding< as itDllserve as a reference sheet #hen presenting a patient to the anesthesiologist(


Anesthesia for Medical Students @fro+ )< aka the Grey Book< although a little dated< does a

great >o' in covering the necessary +a>or concepts and prepares students #ell for the ea+(Toronto &otes are also very useful for a Fuick su++ary of anesthesiology( Students #ill receivea docu+ent a'out pediatric anesthesia< #hich is helpful to read prior to their day at BCCH(There are also online +odules provided that are helpful as an early orientation to anesthesiology<and so+e doctors +ay ask Fuestions in relation to those as #ell. &MS #as generally not foundto 'e that helpful despite the reco++endations< due to it having +ore detail than necessary forstudent purposes(


8$ A 7$&

Students should do the 1 @and increasing nu+'er of +odules availa'le online on ME!7C$L toget a general sense of topic areas( Then< each day< students should choose a topic fro+ theo'>ectives to cover #ith staff throughout the day( Me+oriing co++on drugs @ie( propofol<rocuroniu+< etc( and dosages also goes a long #ay #hen in discussion #ith attendings( !onDt 'e afraid to ask Fuestions throughout the induction process< or reFuest to help or perfor+ varioustasks for hands?on learning and practice(

): The CLE8SH74 GU7!E ; 8otations




3ancouver is a fantastic place to study 'ecause #e are so close to +any great outdoor activities( 7t isunfortunate that +any students 'elieve that the pale tan fro+ the hospital fluorescent lights is a sign

of co++it+ent( Because 7 love the outdoors< 7 +ade a point of hiking< skiing< paddling or >ust#alking on +y days off( *as 7 sacrificing study ti+eI $f course not 'ecause 7 #as that +uch +ore

ecited to sit do#n #ith +y 'ooks after doing so+ething that 7 really en>oy(

GE 7&G 47M4E!" *HA HE !$C $8S E&! $ AS

There is a large focus on phar+acology and cardiacrespiratory physiology( Mechanis+s ofactiondosagesphar+acology of co++on anesthetic agents are all fair ga+e to 'e asked a'out< 'ut students shouldnDt feel like they +ust kno# everything do#n to the letter( Hypotheticalscenarios @e( #hat to do if a patient desaturates< if B4 goes do#n< if there is ecessive 'lood loss<

etc +ay 'e posed 'y the anesthesiologist as #ell( Anato+y of the air#ay or spine is alsoco++only discussed in the contet of intu'ations and epiduralspinal anesthetics(Maternalpediatric anesthesia is only discussed #ith relevant patients at BC*HChildrenDs<unless one happens to 'e in an $8 #here c?sections or pediatric surgeries are taking place< #hich+ay happen if in a co++unity hospital(

HA&!S $&" 48$CE!U8ES -$U GE $ !$ 7& H7S 8$ A 7$&

Anesthesia #ill likely 'e the +ost hands on rotation throughout the year< and there #ill 'eso+ething to do for every single patient that co+es through the $8( 4rocedures that studentsshould epect to get the chance to assist #ithperfor+ include"

Ai r#ay +ana ge +ent procedures Anesthesia induction proce dures

+anual 'ag+ask ventilation of a patient forpre?oygenation or assisted ventilation

73 insertions @peripheral or possi'ly central lines

endotracheal tu'e @ETT place+ents +onitoring eFuip+ent set?up

laryngeal +ask air#ay @LMA insertions spinalepidural anesthetic delivery

etu'ations post?operatively ad+inistering 73 or inhalational drugs

tracheoto+ies @in rare e+ergencies +onitoringdocu+enting patient status





L7EL- GE !U87& G H7S 8$ A 7$&

%ollo# the o'>ectives provided at the start of the rotation< and students should 'e a'le toco+plete all the +ust?sees and +ust?dos for the rotation @+ost of #hich is outlined a'ove(Many of these skills #ill 'e found valua'le throughout the rest of studentsD +edical training

careers< including intu'ations @E8< spinalsepidurals @$'sGyn< ortho< and kno#ledge ofcardiacrespiratory physiology @internal< surgery(


As stated a'ove< read the tet'ook Anesthesia for Medical Students and the Toronto &otes< anddo the +odules< in order to gain a 'road scope of kno#ledge and understanding( Also< there are+any ecellent files and resources availa'le for preparing and kno#ing the kinds of Fuestionsthat #ill 'e on the ea+< 'ut students should 'e a#are that not all of the ea+ #ill 'e covered 'yonly these files( Thus students should read etra files and resources too< on topics such as+aternal and pediatric anesthesiology(

HE %7&AL B$SS" E&! $% 8$ A 7$& EAMS

There is only one ea+ for anesthesia< consisting of :6 +ultiple choice Fuestions in an electronicFui for+at< #ith an hour to co+plete it( The ea+ #ill 'e in con>unction #ith orthopedics@another :6 Fuestion ea+ at the end of the co+'ined +onth length @/ #eeks anesthesia< /#eeks ortho< and #ill take place at the LSC +ultipurpose la' at UBC on the last %riday(Ouestions are fairly straightfor#ard if students have 'een keeping up #ith the +odulestet

reading< and should pose as no surprise to students #ho have adeFuately prepared(




HE MA4" S7 E S4EC7%7CS %$8 HE 8$ A 7$&


Site Here is #here students have +et on

day one in the past"

*here can 7 store +y 'elongingsI

3GH -ou #ill receive an e+ail prior to yourroation #ith instructions on #here toreport

-ou can take a s+all 'ag #ith yourvalua'les into the $8( -our clothes can 'e kept in the $8 change roo+

S4H The day 'efore your shift< go to theanesthesia office in the $8 right #hen youeit the change roo+s( Ask the nurse forthe $8 schedule( -our na+e #ill appearnet to the anesthesiologist that you #ill 'e#orking #ith that day in addition to the$8 roo+ nu+'er and case description(

7nside the $8 there is a nurses lounge#ith roo+ to store your 'elongings< afridge and a +icro#ave( There is nosecure storage so 'ring all your valua'le#ith you( 7t is alright to take a s+all 'aginto the $8 #ith you(

8CH Each +orning< go to the anesthesia officein the $8 right #hen you eit the changeroo+s( $n the 'ulletin 'oards< thereshould 'e a student schedule posted listing#hich anesthesiologist students areassigned to for the day< #hich can 'e cross?+atched to the slate to figure out #hereeactly to go and #ho the first patient ofthe day is(

There are occasionally e+pty lockers inthe change roo+ #hich you can storeyour stuff @+ake sure it doesnDt 'elong toanyone else first.< or you can leave yourstuff in the anesthesia office @'ut carryyour valua'les #ith you in your scru'spockets(

LGH The $8 lounge on the /nd floor( -ou needto call the 7! office ahead of ti+e to haveaccess to the lounge added to your3ancouver Coastal Health 7!(

-ou can reFuest a locker in the doctorDslounge< or >ust leave your 'agcoat @keepvalua'les in your pocket. in a corner ofthe $8 locker roo+(

8GH The $8( -ou #ill 'e directed to theanesthesia office #here you can follo# staffaround for the day(

The $8 change roo+ is the 'est place toleave your stuff< 'ut carry your valua'les#ith you(

BCCH

Go into the $8 on the +ain floor and askthe nurse at the desk #here youDre

supposed to 'e @usually the dental $8

There are locker roo+s on the /nd floorthat should have a free locker to use(

$ther#ise< you can leave your 'ag in thcorner of the $8 locker roo+ or in anopen locker(




BC* 4age the anesthesiologist for the day to+eet up either in the $8< at the first floornursing station< or in the anesthesiologistoffices< in order to 'e oriented and assignedto an $8(

The $8 change roo+ is the 'est place toleave your stuff< 'ut carry your valua'les#ith you(

elo#na

$n your first day< you should sho# up atthe undergrad office(

Leave your stuff in the $8 change roo+ 'ut carry valua'les #ith you(

3ernon

Go to the $8 reception desk on your firstday(

Belongings can go in lockers in the $8change roo+ @code /0):< 'ut studentsreFuire their o#n lock(

errace

Head to the $8 directly to +eet theanesthesiologist for the day(

Leave your >unk in your locker( ThereisnDt +uch roo+ in the $8 #ith t#opeople at the +achine and you donDt#ant your stuff tripping surgeons(

*hat kind of teaching or acade+ic sessions are there at this siteI8egardless of #hich site students are at< all are si+ilar in the sense that the +a>ority ofteaching is in a ) on ) setting #ith the assigned anesthesiologist( Thus the Fuality anda+ount of education provided is highly varia'le depending on staff< 'ut students shouldepect this to 'alance out across all sites and receive an eFual opportunity to learn andpractice procedures( There are fe# residents at +ost sites @fro+ 6?,< and although students+ay #ork #ith and 'e taught 'y residents< there is likely to 'e +ini+al regular interaction#ith the+( $nly so+e sites have acade+ic sessions< and these usually only occur during )?/ +orningslunch ti+es of the +onth(

7s this a good site for so+eone interested in this specialtyI

All the sites provide a+ple opportunity to practice and learn skills and procedures inanesthesia< and are #ell suited for anyone interested in the specialty( Although largercenters +ay 'e 'usier and have less ti+e in 'et#een cases to teach and learn fro+ oneDsanesthesiologist< they do offer +ore opportunities to perfor+ procedures( S+aller centersgenerally have no other students or residents around< and thus provide +ore opportunity toassist or perfor+ all types of procedures( 8egardless of #here students are placed< all aregenerally very happy #ith their rotation and gain a large a+ount of kno#ledge 'y the endof their / #eeks(

*hat are co++on pro'le+s patients at this site haveI

7n general< every site #ill have a good +i of patient cases< and the site director #ill do

their 'est to assign a variety of surgical specialties to students in order for the+ to seevarying aspects and procedures in anesthesia( Students #ill receive +uch learning andpractice in spinalepidural anesthetics during their +aternity day@s< have an opportunity toplace 73s in children during their pediatric day@s< and should 'e a'le to see 'oth short andlong surgical inductions in 'oth healthy and highly co+or'id patients( There should also 'e a+ple opportunity to o'serve ho# to +anage patients #ith difficult air#ays and o'esityat every site( Thus students should not 'e concerned a'out +issing out on certain aspectsof anesthesia 'ased on their location< as all are Fuite eFual(




HE L7S " )6 H7&GS $ &$*

: ADs of anesthesia : co+ponents of air#ay assess+ent

)( Analgesia" patients should eperience nopain throughout the surgery< and havecontrolled pain after#ards

)( +outh opening" should 'e a'le to put /?,finger'readths into the +outh #hen patient opens ias #ide as they can

/( A+nesia" patients should have no+e+ory of the surgery itself

/( thyro+ental distance @TM!" should have at leas, finger'readths of #idth 'et#een the top of thethyroid and the 'otto+ of the +andi'le

,( Aniolysis" patients should 'e cal+ed 'efore and after the surgery

,( prognath" should 'e a'le to put their +andi'leout so their lo#er teeth are in front of their upperteeth

0( Akinesis" patients should 'e i++o'ileand have relaed +usculature

0( Malla+pati score @class 7 to 73" #ith their +outhopen< ho# +uch of the uvula and posteriorpharyn can 'e seenI

:( Autono+ic control" patients should havea sta'le heart and respiratory rate

:( dentition" does the patient have anyloosecappedfalse teeth< or another dental issuethat is an aspiration riskI


A co++on >oke a'out anesthesiologists is to talk a'out the ABCDs of the specialty" air#ay< 'illing< coffee( Although there is so+e truth in this< @there is lots of do#nti+e to get coffee andoperation 'illing codes fro+ the surgeon are often sought< there is far +ore to the specialty(

Anesthesia is a co+ple 'alance 'et#een kno#ledge of physiology and phar+acology< #ithapplications of +any hands?on procedures that reFuire high deterity( Although rarely seen inaction< they need to 'e a'le to think< plan< and act rapidly< should the need arise( But luckily<good anesthesiology +eans that enough preparation and anticipation has 'een perfor+ed so thatpatients re+ain sta'le throughout the entire procedure< and the doctors are free to read< surf the#e'< and +anage their stock portfolios for hours in a day(

Many students thoroughly en>oy their anesthesia rotation< as there is +uch to learn and do( 7t isan eciting specialty< #hich often converts students into this career path after they haveeperienced it( 8egardless of oneDs interests< the skills gained on this rotation are fully applica'le

to a variety of settings< and serve #ell to allo# students to 'eco+e relia'le air#ay +anagers inthe future( As one 8CH anesthesiologist has put it< Jif you donDt learn ho# to properly 'ag apatient 'y the end of this rotation< then #eDve failed as your preceptors( Also< if you canDt 'ag apatient< 7D+ not letting you even touch an intu'ation tu'e< let alone try to insert one(((K





$rthopedics

*ritten 'y Ben =ong< M! /6),Edited 'y La#rence Haiducu< M! /6)0

HE B7G 47C U8E" 7& 8$!UC 7$&

$rthopedics is a / #eek long rotation coupled #ith Anesthesia< and consists of an even +i of 'oth clinic and $8 ti+e( The specialty has 'een descri'ed as applied anato+yD< and certainlystudents should epect to relearn +uch of their MS 'lock kno#ledge fro+ /nd year< including+uscle and 'one no+enclature< as #ell as physical ea+ination skills for +usculoskeletalin>uries( There are a variety of patients< #ith 'oth acute and chronic pro'le+s< that students canepect to see< and su'seFuently learn fro+ the principles of +anage+ent for fractures @oftendenoted as a V sign< tears< and various other in>uries(


The student schedules are varia'le< and are dependent on the rotation site( 7n +ost locations<students should epect to start their day early around 5a+ in order to round on surgical patients<or to receive +orning teaching( This is then follo#ed 'y either a clinic or an $8 day #ith variousorthopedic surgeons< so+e of #ho+ +ay have specific specialiations focussing on only one areaof the 'ody @e( #rist and forear+< lo#er leg and foot< etc( The clinics are very 'usy< andstudents #ill encounter +any cases at a very fast pace( The day ends at varia'le hours< 'utusually students should 'e finished 'y :p+( !epending on the site< students +ay also 'eassigned ti+e in the casting clinic< in a pediatric clinic< or e+ergency consults(


Again< call shifts depend on the site location( So+e hospitals< such as 8CH< do not reFuirestudents to co+plete call< unless they desire to do so( *hen call does occur< it is in?house< andstudents could 'e a#ake through the night seeing e+ergency consults #ith the orthopedicsresident< or sleeping soundly through the night< depending on the varia'le volu+e at each site(Call typically lasts until the net +orning and students #ill 'e released fro+ duties once rounds

have 'een co+pleted on patients(

HE GEA8" *HA $ B87&G 9 CA88-

%or days #hen students are going to 'e in a clinic< they should 'ring the usuals" #hite coat<paperpen< stethoscope in the odd event that one is asked to do so+e pre?op #ork?up onso+eone @listening Fuickly to heart and lungs< vitals( Students can leave the stethoscope in a 'agor pocket< though( A pocket physical ea+ination reference 'ookguide is also Fuite helpful tolook up specific +usculoskeletal tests( An alternative is a s+artphone #ith internet access( Sitessuch as ###(ortho'ullets(co+ or http"toporthoapps(co+ are great resources students can tryand see if they like(




%or $8 days< 'e sure to 'ring student 7! cards to access the $8 #ith @assu+ing oneDs 7! cardhas 'een set up already to give access to the $8.(


4A 7E& S A&! $ HE8 7&%$

4en and paper is the si+plest +ethod( Most sites donDt epect students to take care of a lot of#ard +anage+ent< so nothing fancier is reFuired(


The reFuired tet'ook Essentials of Musculoskeletal Care @availa'le online at Stat.8ef isecellent< 'ut so+e +ay not find it particularly useful in the orthopedic clinic or $8< as itDsfocused +ore to#ards pri+ary care +usculoskeletal in>uries and +anage+ent< rather thansurgical +anage+ent and fracture healing( 7nstead< itDs likely +ore useful for students in theclinic$8 to revie# their hu+an anato+y and fracture typespatterns( Studying past anato+yand +usculoskeletal 'lock notes fro+ second year is a good 'et( Ho#ever< students should still#ork through the assigned readings fro+ the reFuired tet'ook< as this #ill 'e ea+ina'le

+aterial(


8$ A 7$&

Students should study around their cases #hen they go ho+e< and after trying to find out #hatthe net day looks like @ie( in an upper or lo#er etre+ity clinic< in the $8< etc< readingappropriately in advance( %or ea+ple< kno#ing a'out co++on upper etre+ity fractures is apretty good idea 'efore going into an upper etre+ity clinic(

Me+ora'le Mo+ents

$rthopeadics #as +y first JsurgicalK rotation and on+y first day on the $8< 7 discovered a nu+'er ofunepected JproceduresK"

)( The choice of +usic is as i+portant as thechoice of surgical tool

/( Be as prepared to talk a'out last nightDshockey ga+e as you are to descri'e theanato+y of the hip

,( Have a #alk through Ho+e !epot 'efore therotation 'ecause that +ight also 'e a topic ofdiscussion

The 'igger the po#er tool used in the surgery< the+ore fun it is.


Sleep( Many years ago< it #as decided that entrustingstudents #ith health and life of a patient is too si+ple a

task( Therefore< #e no# have to do it #hile sleep deprived.Unfortunately< this leads to nasty conseFuences for your

health< the health of your patients and your a'ility to learn(Make sleep a priority( At ho+e< 7 +ade sure that 7 #as #ell

organied so that there #as little to do to prepare for thefollo#ing day( This allo#ed +e to clock around 5 hours(

And #hen 7 couldnDt get this +uch sleep< 7 #ould often finda Fuiet place during the day for a nap( !uring call shifts< 7

#ould nap in the afternoon #hen it #as Fuiet to +ake surethat 7 had a little sleep under +y 'elt heading into the

evening(




GE 7&G 47M4E!" *HA HE !$C $8S E&! $ AS

!octors tend to ask Fuestions a'out anato+y< as thatDs #hat #e can relia'ly 'e epected to kno#at our level( They +ay also ask a'out su'>ects such as osteoarthritis or other very co++onorthopedic conditions students should have seen already or at least heard of @e( distal radiusfractures< ganglion cysts< etc(

$f course< students should also kno# ho# to descri'e a fracture( Ele+ents include location<

intra? vs etra?articular< type @transverse< spiral< o'liFue< co++inuted< open vs( closed<displace+ent< etc( @see The ListD 'elo#( To go the etra +ile"

no# so+e classifications @e( A$*e'er Ankle %racture classification

no# so+e rulesguidelines @e( $tta#a Ankle 8ules

!$&DT >ust 'lurt out epony+s( Anyone can 'lurt out JCollesD %racture.K P it takes at leasta little +ore thought to say< JThis is a fracture of the distal radius #ith the distal frag+entdisplaced and angulated dorsally #ith respect to the posterior frag+ent( This is also kno#nas a ColleDs fracture(K

!$&DT assu+e that all attendings #ant the a'ove( So+e of the+ really do >ust #antJColleDs fractureK< though +ost do #ant to kno# one is a#are of #hat the characteristicsare(

HA&!S $&" 48$CE!U8ES -$U GE $ !$ 7& H7S 8$ A 7$&

Typically +edical students #ill 'e allo#ed to do so+e suturing< although the eperience variesdepending on the attending physician and the particular situation( So+e students have 'een giventhe opportunity to put scre#s or ?#ires into 'ones< #hile others have helped prep and striptendon grafts( 7n cast clinics< students can help put casts on< re+ove pins< take out staples< etc 'ut

they +ight have to ask to do these things since< as in +any places< an 8& or cast technician doesthese procedures instead of the doctor( The key thing here is to 'e keen and enthusiastic< 'ut notpushy#hinyannoying( Be so+eone theyDre happy to #ork #ith< and the chance to doprocedures #ill co+e up(


L7EL- GE !U87& G H7S 8$ A 7$&

Students should 'e a'le to check off assisting at +a>or surgery< casting< splint application< andsuturing #ith surgical knots( They should also epect to see a variety of fractures and tears in all

areas of the 'ody< as #ell as corticosteroid in>ections into various >oints(





!ue to recent changes in the orthopedics depart+ent and a ne# $rthopedics !irector ofUndergraduate Education 'eing appointed< the previously esta'lished ea+ has 'een revised<and as a result there has 'een so+e confusion as to #hat to study( 8ather than ea+ining fro+the 5/ patient cases docu+ent provided to students< the depart+ent has no# shifted to using theassigned readings fro+ The Essentials of Musculoskeletal Care as the 'asis for the ea+Fuestions( Students do #ell 'y co+pleting these readings< as #ell as studying fro+ Toronto

&otes or other revie# 'ook( The *heeless tet'ook online@http://www.wheelessonline.com/) is also a great reference for +ore details on orthopediccondtions if other 'ooks are not co+prehensive enough( The patient cases docu+ent fro+ pastyears< ho#ever< also serves as a great read for those interested in orthopedics< as it is +ore directlyrelevant to #hat students #ill see in the clinic< $8< and e+ergency(

HE %7&AL B$SS" E&! $% 8$ A 7$& EAMS

There is only one ea+ for orthopedics< consisting of :6 +ultiple choice Fuestions in anelectronic Fui for+at< #ith an hour of ti+e to co+plete it( The ea+ #ill 'e in con>unction

#ith anesthesia @another :6 Fuestion ea+ at the end of the co+'ined +onth length @/ #eeksanesthesia< / #eeks ortho< and #ill take place at the LSC +ultipurpose la' at UBC on the last%riday( As stated< the ea+ Fuestions are 'ased on the assigned readings(

HE MA4" S7 E S4EC7%7CS %$8 HE 8$ A 7$&

Site S4H 8CH SMH LGH 8GH

o find out

#here to go on

the firs t day<

CHEC -$U8

EMA7L for a

+essage fro+

the depart+ent(

Here is #here

students have

+et on day one

in the past"

3aria'le( !r(Stothers sends ane+ail #ith yourschedule >ust prior to

your rotation(

Medical Education$ffice @Base+entLevel at the HealthCare Centre at

62):< to receive anorientation and tourfro+ !r( MikeLe+ke(

8eport to !r(8ichardSch#eigelDs office@across the street

fro+ the hospitalat 6266(

E?+ail !r(Ada+ SidkyDsoffice 'eforeyour rotation

starts( E+ailprovided priorto rotation 'ythe progra+ad+inistrator(

Call !r( 8ichardendallDs office

'efore the rotationstarts( -ouDll get a

e+ail #ith thecontactinfor+ation( &otethat you need to sup your securitypass as #ell(

*here can 7

store +y

'elongingsI

&othing availa'le Peither store in theclinic< or carry yourvalua'les #ith youinto the $8

Lockers are availa'lein the 'ase+ent nearthe lounge and callroo+s(

Lockers areavaila'le in the+edical educationarea(

$8 lockerroo+(

3isitor lockers inthe change roo+(


http://www.wheelessonline.com/)

http://www.wheelessonline.com/)



Site S4H 8CH SMH LGH 8GH

*hat kind of

teaching is done

at this siteI

Typically the 'estteaching is done inclinic( 7n the $8<things are varia'le Pit depends on ho#talkative thepreceptor is( This isa 'usier centre< and

so+eti+es it can 'edifficult to get so+eteaching +o+ents(

Morning teachingrounds are helpful($ther#ise< theteaching is varia'le(So+e studentsreport goodteaching< others notso +uch(

Morning roundson %riday +orningare great( Also<there are noresidents and fe#+edical studentson service< so youget a su'stantial

a+ount of faceti+e(

Teaching isgood< #ith ahealthy a+ountof )") ti+e #ithyoungenthusiastic

orthopods( &oresidents(

Teaching is prettygood( Lots of )")ti+e #ith thepreceptor in 'othclinic and the $8as there are fe#residents and+edical students t

co+pete #ith(

7s this a good

site to choose

for so+eone

interested in

this specialtyI

7t can 'e if youDrekeen P sho# thatyouDre interested< tryto take initiative#ithin your scope@e( get ?ray reFsand fill the+ outahead of ti+e #henappropriate

Again< Fuitevaria'le(

This rotation can 'e a greateperience P the

'alance 'et#eenclinic and theoperating roo+ is:6:6< and thereare consults to deal#ith(

-es P fe#residents +eansyou can #ork ashard as you like#ithout needingto co+pete forface ti+e #iththe staff(

-es P lots of handon and variety ofcases(

*hat are

co++on

pro'le+s

patients at this

site haveI

3ariety of patientsseen P the t#o #eeksare organied on the

'asis of a differentclinic or $8 eachday< so you shouldget a good variety(

At this location<youDll see a lot oftrau+a as all thestaff cover this( Allthe staff are alsosu'specialied< soyou should get adecent variety(

Lots of hip< knee<and shoulderpro'le+s(

Good variety ofpro'le+s( So+etrau+a?specificdays(

Mostly electivesurgeries< not +uctrau+a(

HE L7S " )6 H7&GS $ &$*

: ele+ents of a f racture descript ion : treat+ent +odali t ies for f ractures

)( Classification" closed vs co+pound<hairline vs partial vs co+plete< si+ple vs+ultiple vs co++inuted vs avulsion<transverse vs longitudinal vs o'liFue(

)( conservative +anage+ent" a #atch and #aitapproach< in cases #here healing is epected to occur#ithout intervention due to a non?displaced fracture@e( hairline V(

/( Location" #hich 'one< and #hat part ofitI !oes it involve an articular surface or >ointI 7s it in one location or did forces

travel through 'one to cause fractureselse#hereI

/( soft fiation" 'racing< slings< taping< etc can 'e usedto provide additional support for si+ple fractures<often as a +eans of relieving pain or preventing the

seg+ents fro+ separating due to +uscle contraction(

,( Angulation" is the ais of each 'oneseg+ent not in the sa+e direction< and#hich direction does the ape pointI

,( rigid fiation" casts or splints can 'e used for +orerestriction of +otion to ensure pri+ary 'one healingoccurs(




0( 8otation" is there any co+ponent of spinof the 'one seg+ents in the long aisI Thisis difficult to tell on a plain ?ray< and thusstudents shouldnDt state there is rotation 'ased on this study alone< unless there isvery clear rotation @e( spiral fracture(

0( eternal fiation" ?#ires and eternal 'ars areused to secure 'one frag+entsseg+ents to eachother< and are inserted percutaneously #ithout theneed to cut skin to epose the 'one( These are thenre+oved after 'one healing has occurred(

:( Translation" ho# shifted are the seg+ents

fro+ each other and in #hat planeI Thiscan 'e any#here fro+ )6 to _)66displaced(

:( internal fiation" plates< nails< and scre#s are

secured across fractures onto the 'one to ensure rigidfiation after the skin and tissue has 'een surgicallyeposed( Usually per+anent< 'ut there is an optionto re+ove these later on if desired(


$rthopedics has a stereotype of the 'ra#ny >ock doctor associated #ith it< in #hich +achohu+our is the nor+ and epectation( As #ith all stereotypes< #hatever little truth it +ay have

initially 'een 'ased on is no# gone< and one can find orthopedic surgeons in all shapes< sies< andgenders( 7t is a fast?paced specialty that offers +any interesting eperiences< and can 'e veryen>oya'le for all students( 7n addition< it serves as a crucial revie# of anato+y that +any +ayhave forgotten follo#ing /nd year< and reinforces the i+portance of a strong kno#ledge 'ase ofthe +usculoskeletal syste+ @#eDll all see at least one< if not +ultiple< cases of fractures in ourcareers< regardless of #hich specialty youDre in(

There is often also an presu+ption that orthopedics is a dead?end specialty #ith no >o'opportunities( Although the current e+ploy+ent +arket has 'een stalled< this #onDt re+ain thecase indefinitely< as +any of the senior orthopods #ill soon retire< al'eit at a later age than

nor+ally epected( 8egardless of these details< there is still no short supply of orthopedicresidents and fello#s< all of #ho+ enter the specialty for a love and appreciation of the+usculoskeletal syste+( 8egardless of if one likes orthopedics or not< it canDt 'e denied that anyspecialty in #hich asking for a +allet and chiselD during surgery is not atypical is certainly a cooland uniFue Fuality in itself.





$'stetrics and Gynaecology

*ritten 'y =essica %ong< M! /6),


HE B7G 47C U8E" 7& 8$!UC 7$&

$'stetrics and gynaecology @o'sgyne is a 1?#eek rotation and< depending on #here students dotheir rotation< the split 'et#een o'stetrics and gynaecology can 'e distinct or integratedthroughout the 1 #eeks( $ne of the #eeks is a preceptor #eekD during #hich students areassigned to one o'sgyne physician and #ill spend the #hole ti+e #ith hi+her @clinic< $8< andcall P +ore info on the preceptor #eek can 'e found 'elo#(There are 1 locations to rank preference of and 'e assigned to"

BC *o+enDs Hospital @BC*H and 3GH

8oyal Colu+'ian Hospital @8CH

8ich+ond General Hospital @8GH

LionDs Gate Hospital @LGH

elo#na

a+loops

This can 'e a very 'usy rotation. Ba'ies co+e at all hours of the day or night and students can 'e >ust as @or even +ore sleep?deprived in this rotation than they are during CTU or general

surgery( Ho#ever< +ost call shifts are /0 hrs in?house @fro+ 2 a+ ? 2 p+ and one al#ays goesho+e at 2 a+ @the residents do.( That 'eing said< ho# 'usy students are on this rotation is verydependent on ho# +uch they put into it( Because things tend to happen very Fuickly on thisservice< residents and nurses +ay not have ti+e to page students even if they are asked to. Most#ill +ake an effort< 'ut good co++unication 'et#een students and theresidentpreceptornursing staff< as #ell as consistent follo#?up on patients< are 'oth #ays toensure involve+ent( This is especially i+portant if students are rotating at one of the peripheralsites @LGH< 8CH< 8GH as staff are not as used to having +edical students as at BCCH(


Each student #ill receive a detailed individualied schedule at the 'eginning of the rotation #itha nice +i of clinic and inpatient learning opportunities( Call shifts are approi+ately ) in 1<although not necessarily evenly distri'uted throughout the #eeks(

7f students are not on call< they #ill 'e spending ti+e at various clinics @colposcopy< fertility<+id#ifery< ultrasound or in the $8(




!uring Jpreceptor #eekK< students #ill have the chance to #ork #ith one specific o'sgynedoctor and follo# the+ to their cliniccall$8( Their evaluation over the course of this #eek#ill +ake up a large part of oneDs overall clinical evaluation(

There are t#o acade+ic half days per #eek< usually Tuesday and Thursday +ornings #ithlectures videoconferenced fro+ BC*H to all of the satellite sites( Clinic hours are typically 2 a+? : p+< 'ut should 'e checked ahead of ti+e #ith the clinic office( Call shifts are /0 hours #ithpost?call days off(

Me+ora'le Mo+ents

$n +y first call shift for o'stetrics< 7 had finally gone to 'ed after a 'usyand cray day< 'ut #as paged at , a+ #ith the ne#s that a healthyyoung +other #as a'out to deliver her first 'a'y( 7 headed do#n tola'our 9 delivery< ecited that 7 #as finally going to see a nor+alvaginal 'irth( Things #ent #ell for the first #hile P la'our #asprogressing Fuickly< the +o+ #as doing a great >o' of pushing< andeverything see+ed to 'e going s+oothly( %inally< #ith another 'igpush< the head ca+e out] then nothing +ore happened(Usually< the rest of the 'a'y co+es out Fuite Fuickly and easily once

the head is delivered< 'ut not #ith this 'a'y( The at+osphere in theroo+ed 'eca+e tense( So+ething #as #rong( A nurse ca+e over to+y side of the 'ed< and #hile 7 and a student nurse pushed the +o+Dsknees to her chest< the nurse #as pushing do#n on +o+Ds lo#era'do+en( The o'stetrician #as holding on to the 'a'y< trying to+aneuver her into a 'etter position( Still nothing( An episoto+y #asperfor+ed< despite the +o+ having no pain control on 'oard( The

'a'y #as still stuck( The +o+ #as screa+ing in pain( Theo'stetrician told us to turn the +o+ over onto all fours and then 'ackonto her 'ack( %inally< the 'a'y turned and ca+e free and #as ratherstunned< although #ith a 'it of sti+ulation she started 'reathing and#as okay(That day 7 learned a'out a co+plication of vaginal 'irth that 7 didnDt

kno# eisted P shoulder dystocia< #here the 'a'yDs shoulder gets stuck 'ehind the +o+Ds pu'ic 'one< #hich is an o'stetrical e+ergency( 7 #assorry that the fa+ily had to go through such a difficult 'irth< 'utthankfully everyone #as okay in the end and 7 learned so+ething too.


Clerkship is stressful( Constantevaluations< see+ingly unrealistic

epectations and isolation are only afe# of the challenges( Medial students

are not only not i++une to +ental

illness 'ut are suscepti'le 'ecause ofthese factors( Conditions including

aniety< depression< su'stance a'use<eating disorders< inso+nia a+ongothers are +ore co++on a+ong

+edical students than you +ight epectUnfortunately< +any students fail to

seek treat+ent resulting in a decreaseda'ility to learn< perfor+ and take careof patients( 7f you find yourself even

Fuestioning #hether you +ay 'e at lessthan opti+al health< there are +any

places to reach out to including the$SA< the 4hysician Health 4rogra+and your fa+ily doctor( Taking the

necessary ti+e to care for yourself is noa failure( 7n fact< failing to take care of

yourself is only har+ing you career andyour patients(


There is slight varia'ility depending on the site< 'ut calls are typically /0 hours starting fro+ 5 ? 2a+( Students do get post?call days off( *hen on call for o'stetrics< students #ill usually si+plystay around the #ard and follo# #o+en through the course of their la'our 9 delivery( StudentsDlevel of involve+ent #ill very +uch depend on personal initiative< so students should re+e+'erto ask the nurses andor preceptor to call for any patient issues(




HE GEA8" *HA $ B87&G 9 CA88-

!ress code #ill depend on #here students are scheduled to #ork for the day( The usual 'usinesscasual X? #hite coatstethoscope is appropriate for clinic< #hile scru's are 'est #hen on call(Shoe covers are highly reco++ended if students are #orking on la'our 9 delivery @a+niotic

fluid and uterine 'lood spillage is the nor+. $ne should 'ring along so+e study +aterial in casethere is a 'reak and an opportunity to get so+e reading done( Snacks are also great for 'usy days#hen students +ight not get a chance to gra' lunch on ti+e< as patients +ay need very freFuent

and regular +onitoring during la'our(


4A 7E& S A&! $ HE8 7&%$

So+e students found it helpful to +ake so+e inde cards that they could fill in for each patientthey #ere follo#ing( This is particularly 'eneficial for o'stetrics< #hen one +ay 'e follo#ing+ultiple #o+en in active la'our throughout the course of the day( 7nclude details on eachpatientDs GT4AL< E!!< GBS status< ti+e of +e+'rane rupture< contraction freFuency< vaginalea+ findings< etc(


The faculty?reco++ended tet'ook for this rotation #as Hacker and MooreDs Essentials of$'stetrics 9 Gynecology< 'ut so+e +ay find this to 'e a little too dense and detailed for theirneeds( 7nstead< +any students found Toronto &otes and the Blueprints or &MS 'ooks to 'eadeFuate for ea+ preparation( The depart+ent #ill give students a link for u*ise< a Fuestion 'ank #ith lots of practice Fuestions< #hich are very useful for revie# studying( Students alsoliked 4retest and Lange O9A as further preparation for the &BME(


8$ A 7$&

Students should read through their revie# tet'ook or Toronto &otes #henif they get a Fuiet+o+ent on the #ards( Study around the cases that are seen( As ea+ ti+e nears< try goingthrough as +any practice Fuestions as possi'le( Looking over so+e of the S$GC guidelines canalso 'e useful for the #ard(

GE 7&G 47M4E!" *HA HE !$C $8S E&! $ AS

!o epect to 'e Fuied regularly 'y doctors and residents< as there can 'e lots of spare ti+e in 'et#een checking up on la'ouring patients( Most Fuiing #ill 'e centered around pregnancyconditions and risks< as #ell as the process and +anage+ent of delivery( 7n the $8< Fuestionsregarding anato+y and function should 'e epected as #ell( Co++on Fuestions to epect @andthus to kno# #ell are"

*hat are the stages of la'ourI

*hat is this structure @pelvic anato+yI




Maternal co+plications of pregnancy P gestational hypertension< gestational dia'etes<antepartu+ 'leeding< postpartu+ he+orrhage< infections

%etal co+plications of pregnancy P s+all for gestational age< oligopolyhydra+nios< 8hinco+pati'ility< post?ter+ pregnancy< +iscarriages

Approach to a+enorrhea< +enorrhagia< etc(

HA&!S $&" 48$CE!U8ES -$U GE $ !$ 7& H7S 8$ A 7$&

There are a variety of procedures that students #ill have an opportunity to 'e involved #iththroughout the rotation< 'oth in la'our and delivery< the $8< and the clinic( The a+ount ofopportunities to do this depend highly on the studentDs initiative and +otivation< and this 'eginsfirst #ith introducing oneDs self early on in the la'our process to the patient and her partner< as#ell as the nurse( The 'etter they kno# the student< and can see he or she is relia'le and caring<the +ore theyDll trust and allo# the student to do procedures such as an internal ea+< oractually delivering the 'a'y.

The epectation is that 'y the end of this rotation< students should 'e reasona'ly co+forta'le#ith the +anage+ent of an unco+plicated vaginal delivery( Most students had the chance toperfor+ a fe# vaginal deliveries on their o#n over the course of the rotation( There should 'ea+ple opportunity to assist in or even personally perfor+ the delivery of placentas< suturing ofvaginal tears< insertion of foleys< and coaching the patient through contractions( !uring clinics<students should 'e a'le to perfor+ routine pregnancy physical ea+s @including fetal heart rateassess+ents 'y dopplers< pap s+ears< ST! and other infection s#a's< 'iopsies< and possi'ly evenultrasounds depending on the availa'ility #ithin the preceptorDs clinic office( There #ill also 'ethe chance to assist in C?sections and other procedures in the $8 @hysterecto+ies< !9C< etc((


L7EL- GE !U87& G H7S 8$ A 7$&

Students should epect to co+plete +ost of the follo#ing #hile on call or during the scheduledclinics( Any ite+s +issed should 'e revie#ed independently< as they are i+portant #hen itco+es to ea+ ti+e(

Must?!os Must?Sees

3aginal delivery Antepartu+ assess+ent

Assist at C?section or +inor+a>or surgery 4regnancy co+plications

4elvic ea+ and 4ap test La'our 9 deliveryUrinary catheter insertion @fe+ale 4ostpartu+ assess+ent

Assess+ent of la'our" a'do+inal andvaginal ea+s

3aginal 'leeding

Suturing of vaginal tears A'do+inal painpelvic +ass





8eading over a revie# tet of choice and doing so+e practice Fuestions on u*ise< 4retest orLange #ill help #ith preparation for the &BME( The $SCE is generally Fuite fair( 8ead aroundcases and go over a general approach to co++on o'sgyne clinical conditions( 8ecurring $SCEstations include the follo#ing topics @to #hich students should kno# the approach"

8outine prenatal care and prenatal screeningdiagnostic tests

Gestational dia'etes

Hypertension in pregnancyHELL4 syndro+e

7ntrauterine gro#th retardation

4ostpartu+ he+orrhage

Ectopic pregnancy

Manage+ent and co+plications of +ulti?gestation pregnancy

A'nor+al vaginal 'leeding 4elvic infla++atory disease @47!

Contraception ? 'oth hor+onal and non?hor+onal options< in the for+ of oral+edications< intrauterine devices< or other +ethods

4ap s+ear P schedule for follo#?up if nor+al or a'nor+al< ho# are histological changesclassified< indication for colposcopy etc(

ST7s and vaginalcervical s#a's @e( gonorrhea< chla+ydia< GBS

$ncologic screening< diagnosis< and +anage+ent of gynecological cancers

Urinary incontinence prolapse

&or+al la'our and delivery ? sho# the cardinal signs on a +odel

A'do+inal ea+ @including LeopoldDs +aneuvers sho#n on a +odel




HE %7&AL B$SS" E&! $% 8$ A 7$& EAMS

The $'sGyne ea+s consist of an &BME and an $SCEoral ea+ during the last #eek of therotation(

The &BME ea+ is a standard )66 +ultiple choice Fuestion ea+ that is provided 'y theA+erican &ational Board of Medical Ea+iners< to 'e co+pleted in a span of / hours :6+inutes( 16 or greater is reFuired to pass the ea+( Each Fuestion typically consists of a

patient vignette illustrating a presenting case #ith associated investigations and results< follo#ed 'y a clinical Fuestion #ith @usually : +ultiple choice selections( The Fuestions are nota'lylonger reads than previously encountered +ultiple choice Fuestions fro+ )st and /nd year+edicine ea+s< and have 'een kno#n to contain etraneous or ecessive details not reFuired toans#er the Fuestion( As such< it is reco++ended that ea+inees first gli+pse #hat the Fuestionis asking< then read Fuickly through the vignette 'efore providing oneDs 'est ans#er and +ovingon to the net Fuestion( Ti+e can 'e lacking in the ea+ if every Fuestion is read +eticulouslyand overanalyed.

The $'sGyne &BME is one of the +ore straightfor#ard &BME ea+s one #ill #rite in third

year< and should not present any +a>or surprises in ter+s of kno#ledge range and depthreFuired( The $SCEoral ea+ consists of eight )6?+inute stations< during each of #hichstudents #ill discuss a clinical case #ith the ea+iner< revie#ing the diagnostic approach and+anage+ent of o'stetricgynecologic co+plaints @as listed a'ove(

HE MA4" S7 E S4EC7%7CS %$8 HE 8$ A 7$&


BC*H3GH

* h e r e t o g o o n t h e d a y o n e "

$'sgyne is split into t#o ,?#eek 'locks< #ith , #eeks at BC*H for o'stetrics< and , #eeks ofgynaecology at 3GH( The )?#eek preceptorship is usually during the gynaecology 'lock and #illreplace one #eek of 3GH service(

%or o'stetrics at BC*H< students #ill usually start the day at handover rounds in the staff loungeat 65,6< possi'ly follo#ed 'y a thirty?+inute case?'ased teaching session fro+ the chief residentand +aternal fetal +edicine doctors( %or gynecology at 3GH< handover rounds start at 61,6 inthe 0C fish'o#l< and also involve patient rounding(

* h e r e t o s t o r e y o u r s t u f f "

Call roo+s and lockers at BC*H are located at /&0 @across fro+ the entrance to the neonatalnursery( At 3GH they are located on Centennial 4avilion< /nd floor(




e a c h i n g d o n e a t t h i s s i t e "

Students #ill generally 'e +ost involved if they follo# unco+plicated +ultiparous deliveries(L9! and Cedar are good places for +edical students since the deliveries there tend to 'e routine(

7t is a good idea to try to pick up patients that are follo#ed 'y G4s< although this +ay not al#ays 'e possi'le as Level ) patients take precedence #hen oneDs help is needed( Many of the G4s arevery interested in teaching and allo# +edical students to really take part in the deliveries< +oreso than #ith the on?call o'stetricians( 7nfor+ation a'out each patient can also 'e o'tained on theco+puter< #hich su++aries the patientDs gravida< co+plications< and cervical dilation @at last

3E( !rop in on patients freFuently to check ho# la'our is progressing(

3 G H d e t a i ls "

The volu+e of nor+al gynecology at 3GH tends to 'e Fuite lo#( 8ounds start at 61,6< 'ut +ost+ornings there are fe# patients to round on< although at ti+es students +ay 'e asked to helpround on gyne?oncology patients( %ollo#ing rounds< students #ill either go to clinic or to the$8( Students are on call #ith a resident @#ho does ho+e call and there tends to 'e varia'levolu+e so there #ill likely 'e a+ple opportunity for study(

Gyne?oncology $8 days are +ainly o'servational and unfortunately +ost of the ti+e students

cannot scru' in as +uch of it is laparoscopic and there are al#ays residents and fello#s around(UBC $8 days are a 'it 'etter< as students tend to 'e a'le to scru' in< and can assist in

hysterecto+ies< etc( The gyne?oncology tea+ is a very strong group< though students only getone half day in the staff clinic(

The assign+ent of clinic varies fro+ student to student" students +ay get one half day in the 8E7clinic or none at all< t#o days in the $8< and possi'ly an afternoon in the +aternal fetal +edicineclinic and t#o afternoons in the fa+ily practice +aternity clinic( These clinics are all veryinteresting and allo# a lot of hands?on practice of clinical skills(

There are #eekly grand rounds at 'oth BC*H and 3GH( At BC*H there are also #eekly %etal!iagnostic Service 8ounds and 4erinatal&eonatal Co+'ined 8ounds< 'ut attendance isvoluntary( All students are reFuired to prepare a ):?+inute presentation on a selected o'sgynetopic< #hich is presented to the rest of the group(

G o o d s i te f o r s o + e o n e i n t e re s t e d i n $ ' s G y n e I

7f interested in o'sgyne< BC*H3GH is a reasona'le choice as students #ill 'e a'le to #ork#ith the residents and see lots of high?risk o'stetrics( Ho#ever< it +ay 'e difficult to findopportunities to interact #ith $'sGyne staff< and there +ay 'e less opportunity to perfor+nor+al deliveries on oneDs o#n< as there are only , call shifts at BC*H @the other , are at 3GH(Having a variety of residents can 'e helpful for teaching< 'ut as a result students +ay not 'e first

assist in the $8 and there are also fa+ily practice residents around #ho need their share ofdeliveries( 7n general< there is little ti+e spent #ith a particular doctor ecept during thepreceptor #eek( A lot of the eperience at BC* depends on #hich residents one is #ith( Thechief residents are great and really interested in teaching< 'ut so+e residents do not really #ant orcare to have +edical students around( Call shifts are not al#ays very structured and studentsreally have to 'e proactive or they can finish a shift #ithout having seen anything(




C o + + o n p a t i e n t p r o 'l e + s "

Students #ill see a nice range of 'oth unco+plicated and high?risk pregnancies at BC*H( Thepatient volu+e in gynecology can 'e lo#< 'ut one #ill get a chance to see so+e interesting gyne?oncology cases(

8ich+ond

* h e r e t o g o o n d a y o n e "

Students #ill get a site tour and orientation fro+ the !SSL @!r( Laura Heslip on the first day(

As this is a co++unity hospital< +orning rounds are not as for+al as at BC*H3GH< andstudents are generally not reFuired to attend +orning handover as the staff tend to do this #itheach other through phone or e+ail( =ust sho# up at the 'irth centre or clinic as scheduled< and 'e prepared to learn.


Students can store their 'elongings in the lockers 'y the call roo+s or in the changeroo+ 'esidethe 'irth centre @,rd floor(


The volu+e at 8ich+ond is +ore varia'le< #ith so+e nights 'eing very 'usy and others 'eingvery slo#( Sho#ing interest and initiative is key to a good rotation here( The docs #ill givestudents a lot of hands?on eperience if they #ant to 'e involved and nurses +ay call students ifthey are keen @'ut donDt count on it(

Students #ill spend a lot of ti+e at the &oakes Clinic @8GH Maternity Care Clinic run 'y G4s#here they #ill get good )") teaching( The nurses are also an invalua'le educational resource inteaching vaginal ea+s and fetal +onitoring( 7t helps to pro+pt the docs and nurses #ithFuestions if students #ant the+ to teach so+ething(

%e# gynecology cases co+e through the E+ergency #hen students are on call so +ost of thegyne eperience #ill 'e gained during preceptor #eek and during surgeries(

!r( Heslip arranges t#o afternoons of organied teaching for the students at this site( Usuallythis #ill involve a couple of students preparing a short presentation on an o'sgyne topic of theirchoice and presenting it to !r( Heslip and the other students(


Students have generally en>oyed their ti+e at 8ich+ond for this rotation( Because it is a s+allercentre< students #ill pri+arily see unco+plicated pregnancies and deliveries( The volu+e ofgynecology is Fuite lo# so students #ill need to study this +aterial on their o#n for ea+

preparation( That 'eing said< there are usually no residents at 8ich+ond @perhaps the occasionalfa+ily practice resident< so as the only learners around students can get a lot of one?on?oneteaching fro+ staff(


&or+al pregnancy and la'ourdelivery< vaginal 'leeding< ectopic pregnancy(




Lions Gate


Students #ill get an orientation on their first day at the la'our 9 delivery #ard(


There are lockers availa'le on the #ard(


The #orkload during calls tends to fluctuate( The rotation is designed as a +i of o's and gynethroughout the entire 1 #eeks( The schedule is organied to include approi+ately t#o +orningsor t#o afternoons at the Lions Gate Maternity Clinic @run 'y G4s< t#o $8 days< one afternoonat a +id#ifery clinic< one #eek #ith a single preceptor and on?call duties @usually ) in 0( Thereare also the other clinics @infertility< gyne?onc< +aternal fetal +edicine< #hich the rest of thestudents also rotate through(

The Maternity Clinic #ill 'e a very helpful part of the rotation for +ost students as they seepatients and ne#'orns on their o#n and perfor+ prenatal histories< physical ea+s as #ell asne#'orn ea+inations( The physicians at the clinic are all great( There is lots of hands?on

eperience during call @#hich is al+ost al#ays scheduled #ith oneDs preceptor< includingconsultations in the E8 or the #ards< assisting at urgent Cesarean sections or other gynecologicalsurgeries as #ell as vaginal deliveries( The E8 consults can range fro+ 6 P 0 per call( Students+ay not see a lot of gynecological conditions unless they have consults or are in a preceptorDsoffice( Studying the co++on gynecological conditions on oneDs o#n #ould 'e i+portant for the$SCE and the &BME( All of the o'stetricians at LGH are great to #ork #ith( Also learn fro+the nurses. All of the+ are very eperienced in +anaging patients in la'our(

There are #eekly teaching rounds #ith different attending staff< as #ell as infor+al student?to?student and staff rounds presentations(


As #ith +ost co++unity hospitals< students #ill see +ostly unco+plicated pregnancies anddeliveries here( As the only learners @no residents< students #ill have lots of opportunity to 'einvolved #ith deliveries and acting as first assist in the $8(


&or+al pregnancy and la'ourdelivery< ectopics< +enorrhagia< a+enorrhea(

8oyal Colu+'ian


Students #ill receive an orientation at la'our 9 delivery on their first day(


There are lockers 'y the call roo+slounge in the 'ase+ent(





The 1?#eek eperience co+'ines o's and gyne< #hich keeps the days varied #ith options toparticipate in deliveries< C?sections< or gyne surgeries such as hysterecto+ies( The environ+ent isvery friendly and non?stressful< #ith +ost doctors 'eing eager to teach( There are #eeklyteaching rounds #ith staff(

S c h e d u l e a t t h i s s i t e "

Students #ill 'e on?call #ith a resident and things can get pretty 'usy( Epect to arrive around 5

a+ and stay in hospital until a+ the follo#ing day( $ccasionally one can get as fe# as /?0hours of sleep 'ut other ti+es one +ight get lucky and sleep through the night( !ays on?call areflei'le in ter+s of #hat one #ants to do< 'ut itQs i+portant for the student to 'e proactive and getthe nurses and unit?clerk to call for the deliveries< other#ise itQs easy to +iss deliveries during theevening and night(

G o o d s i te f o r s o + e o n e i n t e r e s te d i n o ' s g y n e I

8CH is a large centre #ith high patient volu+e( Students #ill tend to see +ore o'stetrics thangynecology at this site( There are +ore learners around than at the co++unity hospitals< 'ut ifstudents are keen to get hands?on eperience< they should try to spend ti+e #ith the G4 patients<

as residents #ill usually get first di's on the +ore co+plicated cases and C?sections( 7tQs a greathospital and a good chance to get hands?on eperience(


&or+al pregnancy and la'ourdelivery< vaginal 'leeding(




HE L7S " )6 H7&GS $ &$*

: aspects to descri'e on an internal ea+

of the pregnantla'ouring patient

: aspects of a tocograph to descri'e

to classify as a nor+ala'nor+al

tracing

)( Cervical dilation

" ho# open is the cervi@closed< )? c+< or fully dilated< and at #hat rate

of dilation is it openingI

)( Baseline rate

" ))6?)16 'p+ is nor+al@look for long relatively sta'le seg+ents of

tracing that only flutter a little in rate

/( Cervical efface+ent

" ho# thick is the cervi@stated fro+ 6?0 c+ in length< &$T efface+entpercentage< #hich can 'e confusing and varia'le inpatientsI

/( 3aria'ility

" 1?/: 'p+ is nor+al+oderate varia'ility< #hile less< +ore< orsinusoidal for an etended period of ti+e isa'nor+al and concerning

,( Station

" ho# far do#n is the fore+ostpresenting part in relation to the ischial spines@fro+ ?, to X,< 'ut in practical use< should onlyrange fro+ ?/ to X/I

,( Accelerations

" _ / accelerations #ith peak _ ): 'p+ for ): seconds @in ter+ or _)6 'p+ for )6 seconds @in pre?ter+ isnor+al

0( Me+'ranes " is the +e+'rane still intact< feltas a 'ulging #ater 'alloon in the +iddle of thedilated cervi @donDt push too hard or itDll rupture.I

0( !ecelerations " no decelerations oroccassional varia'le decelerations [,6seconds is considered nor+al( Longvaria'le or late decels are a'nor+al(

:( 4resenting part " if the +e+'ranes haveruptured< feel for the fontanelles and sagittal sutureto deter+ine the orientation of the head @left orright $A$4< or transverseI

:( Sta'ility " has this tracing re+ainedrelatively the sa+e over ti+e< or have there 'een any changes to its appearance orcharacteristics recentlyI 7s the nurseconcerned at all #ith the tracingDs sta'ilityI





$'stetrics and gynecology is one of the +ost uniFue rotations< and provides you #ith veryspecial opportunities to fully participate hands?on in patient care( Many students feel privilegedto 'e a part of the >oyous occasion of 'irth< and the parents are often etre+ely appreciative ofthe role students have played in their care( Although at ti+es it can 'e +essy @donDt #ear niceshoes or clothes.< getting your hands dirty is the $&L- #ay to do o'sgyne( &o learning #ill 'egained if students are not keen and proactive in this rotation(

Get involved in assessing #o+en #hen they are ad+itted< or introduce yourself early on in thela'our process 'efore the patient 'eco+es too distracted and is in too +uch pain to ackno#ledgeyour eistence( Make sure to check in on the+ on a regular 'asis through the course of theirla'our< and provide any reassurance or assistance they +ight reFuire @this +ight even 'eso+ething as si+ple as a cool soaked to#el for their forehead.( &urses play a key role in+anaging la'our< so introduce yourself to the nurses taking care of your patients and ask the+ tocall you for any issues so that you can get involved< or #hen theyDre planning to do an internalea+ so that you can o'serve or even practice( They are also a great source of kno#ledge andeperience to learn fro+( 8e+e+'er< if neither the patient nor nurse kno#s #ho you are and

they are not co+forta'ly acFuainted to your presence in the roo+< you certainly #onDt even 'e#elco+e to stay in the roo+ co+e delivery ti+e< let alone actually catch the 'a'y.

So+e pregnant #o+en feel unco+forta'le #ith having a +ale student in the roo+ @there has 'een the odd fe+ale student asked to leave as #ell.( !o not feel discouraged or offended if thishappens to youR it certainly isnDt anything personal< si+ply that the patientDs co+fort andpreference is the priority( There #ill 'e +any future opportunities in #hich you #ill 'e#elco+ed to participate( The 'est advice to increase the likelihood that a patient #ill allo# youto participate in her care is to try to +eet the #o+an early in her la'our @i(e( fro+ ad+ission ifpossi'le or to stick #ith either a fa+ily doc< resident< or o'sgyne and have the+ introduce you

as a part of the tea+( Also< #hen you initially +eet the patient< +ake a conscious effort to 'e#ar+ and caring( S+ile @'ut not in a creepy fashion< and donDt rush the initial patient intervie#(7t is easy to forget to do this through , a+?#aning?caffeine?'lood?level fatigue(

Although it +ay 'e true that +any students have in +ind a specialty in #hich they #ill rarelyencounter +aternity patients and #onDt reFuire this kno#ledge< that is no ecuse to slack off orput in a half?hearted effort( -es< if you choose to< you can hide yourself in the 'ackground andnot 'e called for anything< 'ut keep in +ind that hands?on learning is a +eans to properlyprepare for the &BME and $SCE< and thus students should seek as +uch eperience andopportunity as possi'le( Be proactive< and thereDll 'e lots to see and do.





$phthal+ology

*ritten 'y Sally e< M! /6)0


HE B7G 47C U8E" 7& 8$!UC 7$&

$phthal+ology is a )?#eek rotation and is interchangea'le in the schedule #ith der+atology<another ) #eek rotation( The specialty focuses on the eye and includes various diseases andconditions that affect vision such as cataracts and glauco+a( Students #ill rotate 'et#eengeneral and su'specialty clinics< and there +ay 'e an opportunity to o'serve ophthal+ologicsurgeries as #ell( The #eek is +ostly spent at 3GHEye Care Centre< and students #ill seeoutpatients that are usually other#ise healthy(


A typical day starts at 2a+ and ends 'et#een 0?:p+( Students are assigned to a different clinicfor each half?day and are epected to call in advance to confir+ the start ti+e or their attendance(Clinics vary fro+ student schedule to schedule< and can include the general clinics< the residents

clinic< or su'specialied clinics focused on glauco+a< the anterior cha+'er< or the retina(Students #ill also have an afternoon in the suturing #et la'< in #hich they #ill have the

opportunity to practice tying +icrosutures @)6?6 suture. under +icroscope visualiation on pigeye'alls( There +ay also 'e an afternoon scheduled for students to o'serve cataract andglauco+a surgeries in the $8( The #eek ends #ith the +ultiple choice ea+ on %ridayafternoon(

Me+ora'le Mo+ents

Medicine is full of fancy procedures designed tohelp the doctor distinguish 'et#een health anddisease( There are at least a fe# that 7 a+ sure youhave found yourself trying to convince yourself thatyou do in fact see the target( $'serving thety+panic +e+'rane< noting erly B lines on C8

and successfully finding the optic nerve onfundoscopy are >ust a fe# ea+ples( 7t #as not until+y final day of +y ophthal+ology rotation that 7finally found the optic nerve and #as 7 ecited.Thanks to the patience of a #onderful attending< 7no# a+ confident in +y a'ility to use thatepensive fundoscope.


Clerkship can 'e lonely( Even in 'usy hospitals you +ayfind yourself #ithout any +edical students #ith #ho+ toshare stories< advice< encourage+ent and frustration( Thiscan 'eco+e very trying as often students feel as if they arethe only one that is putting up #ith an intense patient loador negative feed'ack( 7f you can +ake ti+e to get together

#ith your peers you can have a positive i+pact on all ofyour eperiences( But even saying JhelloK in a 'usy #ard#ill help 'oost the +orale of your friends( Co++unity<

although see+ingly a'sent fro+ clerkship< is integral to yousuccess as a clerk(





There is no overnight call in ophthal+ology scheduled for students( Ho#ever< if students do nothave a clinic scheduled< they +ay 'e assigned to take calls during the dayti+e @although this israre and unlikely< as the residents donDt generally have regular interaction or contact #ithstudents(

HE GEA8" *HA $ B87&G 9 CA88-

Generally< students do not need to 'ring their o#n ophthal+oscope< as every clinic #ill havethese availa'le( Ho#ever< so+e preceptors epect you to 'ring your o#n in order to practice #ithone youDre fa+iliar #ith< and this #ill 'e stated on the student schedule( &onetheless< studentsare a'le to pass the ophthal+ology #eek #ithout needing an ophthal+oscope of their o#n(Beyond this< students should carry paper and pen #ith the+ as per usual< as #ell as +ultiple

copies of their evaluation for+s and attendance sheet< and a copy of the +ini?CE evaluation(After each clinic< students need their preceptors to sign their attendance sheet and fill out an

evaluation for+< and these #ill 'e su'+itted to the progra+ assistant on the ,rd floor of the EyeCare Centre at the end of the #eek( Students should also 'ring their #hitecoat< as preceptors

+ay #ish the+ to #ear it in the clinic setting(


4A 7E& S A&! $ HE8 7&%$

Students have not found it necessary to keep track of patients in detail as they are generallyoutpatients< and students do not attend the sa+e clinic +ore than once(


The reco++ended tet'ook is Basic ophthal+ology th ed 'y 8ichard Harper @/6)6( 7t isavaila'le at the ad+inistration office in the Eye Care Centre and can 'e loaned out for theduration of the rotation( Students #ill also 'e sent a file #ith links for various topics taken fro+a C!( As it is only one #eek long< it is unlikely students #ill have ti+e to read a fullophthal+ology tet'ook during this ti+e< nor is this necessary(


8$ A 7$&

Students +ay 'enefit fro+ a Fuick revie# of +aterial on eye anato+y and co++on conditionssuch as cataracts and glauco+a prior to the start of the #eek to fa+iliarie the+selves #ith thespecialty( There is also +ore than adeFuate ti+e to study in the evening regarding any ne# oruniFue conditions encountered #hile in the clinic during the day(




GE 7&G 47M4E!" *HA HE !$C $8S E&! $ AS

As the clinics can 'e 'usy< ho# +uch students are asked Fuestions vary fro+ preceptor topreceptor( *hen this does occur ho#ever< epect Fuestions such as"

Can you see the fundusI !escri'e #hat you do or do not see there(

Eye anato+y and +ethodical slit la+p ea+(

The differential diagnoses for red eyes< inclusions on fluorescein ea+< etc(

8elevant aspects of an eye disease history

Ho# to +easure and record visual acuity for distance and near vision< 'oth #ith and#ithout correction and #ith pinhole #here appropriate(

Ea+ine pupillary response @direct< indirect< acco++odation

HA&!S $&" 48$CE!U8ES -$U GE $ !$ 7& H7S 8$ A 7$&

As ophthal+ology is highly focused on the eye< there are essentially only , procedures students

#ill need to perfor+ during their rotation"

!irect ophthal+oscope" ea+ine the fundus to visualie the optic disc< +acula< vessels< and anya'nor+alities of the retina

Slit la+p" ea+ine eternal eye structures @lids< lashes< and con>unctivae and anterior seg+ent@cornea< anterior cha+'er< iris for a'nor+alities

3ision testing" this can include visual acuity< etraocular eye +ove+ents< pupillary refle< 8A4!testing< colour vision testing< peripheral field testing< etc(

Students #ill also get the opportunity to practice suturing on pig eye'alls #ith )6?6 fila+entsutures under +icroscope visualiation in the #et la'(


L7EL- GE !U87& G H7S 8$ A 7$&

Students #ill o'tain a -ear , rotation procedure and patient encounters +ust seedo list< #hichthey +ust log on $ne0:( By the end of the year< students +ust have perfor+ed )6ophthal+oscopic ea+inations @direct and )6 slit la+p ea+inations @this shouldnDt 'e difficultto co+plete( Students are also reFuired to see ) patient #ith a+'lyopiastra'is+us and ) patient

#ith cataracts(

Aside fro+ the course reFuire+ents< #hat you see depends on the clinics assigned and your o#ninterest( -ou +ay 'e encounter" age?related +acular degeneration< cataracts< con>unctivitis< 'lepharitis< chalaion< hyphe+a< corneal foreign 'ody or a'rasion< dia'etic eye checks< openangle glauco+a< posterior vitreous detach+ent< retinal tears< preseptal or or'ital cellulitis<refractive errors< central serous retinopathy< and various other conditions(





The 'est +ethod of studying is to read and revie# the ecellent files and study +aterialsavaila'le fro+ past +edical students @>ust ask your 'uddy.( 7n addition to reading this revie# fileas #ell as the reco++ended tet'ook< students can also read around various patient cases theysee in clinics using the reference 'ook of their choice @Toronto &otes is al#ays a good 'et(

HE %7&AL B$SS" E&! $% 8$ A 7$& EAMS

The ea+ is )66 +ultiple?choice Fuestions in an hour @donDt #orry< the Fuestions are shorter than&BME Fuestions.< and is #ritten at the Eye Care Centre on the %riday afternoon of the rotation(7t is fairly straightfor#ard< presu+ing students have read the ecellent files and study resources

availa'le fro+ past +edical students(

There is also a +ini?CE that should 'e co+pleted so+eti+e during the #eek< in #hich a doctorneeds to o'serve you operate a slit la+p and perfor+ a direct ophthal+oscope ea+ in order toevaluate you( Try to co+plete this as early in the #eek as possi'le< as so+e clinics are etre+ely 'usy and the preceptor #ill not have ti+e to conduct a studentDs +ini?CE( The residentDs clinic

+ay 'e an ideal ti+e to co+plete this< as it is generally less 'usy and the residents are al#ays keento teach(

HE MA4" S7 E S4EC7%7CS %$8 HE 8$ A 7$&


Site 3GH @All students are +ainly at this site

Here is #here

students have +et

on day one in the

past"

Go to the Eye Care Centre @ECC for an instructional session #ith theresident in the +orning( There #ill usually then 'e an teaching sessionfollo#ed 'y an afternoon clinic( &or+ally< you are assigned to a cliniceach +orning( 7f not< #rite do#n your pagerphone on the #hite'oardso the resident can call you if there is a consult(

*here can 7 store

+y 'elongingsI

7f you are in the clinic< you can keep your 'elongings in the residentDslounge in section ! of the ECC @no guarantees of security< in the clinioffice spaces itself< or an MSAC locker( 7f you are on call< carry your 'elongings #ith you(

*hat kind of

teaching or

acade+ic sessions

are thereI

There is a useful and fun corneal suturing #orkshop( -ou also have

so+e lunch?ti+e teaching #ith a resident( Many preceptors are alsoecellent and happy to teach students(




7s this a good site

for so+eone

interested in this

specialtyI

Since there is no student choice as to #hich site they #ill 'e at and thisrotation is only a #eek long< students interested in ophthal+ology as afuture career +ust select +ore ophthal+ology electives in 0th year( 7ngeneral though< this rotation #ill provide a good eperience for anystudent to learn and revie# their ophthal+ology kno#ledge and skills(

Co++on patient

pro'le+s at this site

The co++on presenting pro'le+ depends on the clinic that you are in(-ou +ay 'e assigned to clinics in general ophthal+ology< retina<

cornea< glauco+a< pediatrics< etc(

HE L7S " )6 H7&GS $ &$*

: steps to direct ophthal+oscopy : steps to a slit la+p ea+

)( 4atient set?up"

? Ensure patient is sitting straight? Ad>ust chair height so the patientDs eye level is >ust 'elo# your shoulder height? Have patient focus on distant spot on #all andtell the+ to look $&L- at this point #ith B$THeyes @this is crucial< 'ecause if the patient +ovestheir gae around< youDll soon 'eco+e diy anddisoriented.

)(4atient set?up"

? Ensure the patient is sitting straight< and havethe+ place their chin on the support< #iththeir forehead against the strap? Ad>ust the patientDs height< the slit la+pta'leDs height< and the slit la+p height so thatthe patientDs eye level is at the 'lack lines onthe vertical 'ars< and the eyepieces are roughlyat your eye level

/( Ea+iner set?up"

? Turn the roo+ lights off< leaving only a di+ light

source on directed a#ay fro+ the patient< orleaving the door open? Ad>ust the ophthal+oscopeDs light setting to thedesired setting @generally the +id?sied circle at+ediu+ 'rightness is 'est to start( ? Set the focusdial to the appropriate X? eye prescription<depending on if the ea+iner is or isnDt #earingtheir glasses for the ea+(? Take a sta'le stance< 'ending yourself to 'ringyour eye to the patientDs eye level( Sta'ilie

yourself 'y gra''ing onto the shoulder of thepatient or chair #ith your non?scope hand(

/( Slit?la+p set?up"

? Turn the roo+ lights off and the slit la+p on

@the s#itch is usually on the edge of the nearside of the slit la+p platfor+? Unlock the slit la+p fro+ its locked position 'y unscre#ing the securing device on thehoriontal 'ars< so that the slit la+p can slidearound on top of the platfor+? Select the desired light colour @nor+al lightor the 'lue light< ad>ust the slit la+p #idth to 'e only a fe# +illi+etres in thickness( Thevertical height should 'e /c+

? Ad>ust the vie#ing eyepieces so that theinterpupillary distance +atches your eyes? Slide the slit la+p into position in front ofone eye< and 'egin vie#ing the patientDs eye




,( Approach"

? Look through the scope #ith the sa+e eye as thepatientDs eye 'eing ea+ined( $rient your gae sothe light is directed at the patientDs pupils(? lean closer and closer in< at an ): degree angleon the te+poral side< #hile continuing to focus onthe patientDs pupil

,( Eternal structures"

? Ea+ine the lids< lashes< and lacri+a forpro'le+s like infla++ation @e( 'lepharitis orother a'nor+alities @e( ingro#n lashes

0( $rient"

? $nce you can look into the patientDs pupil at the 'ack of the eye< search for land+arks such asvessels< and trace the+ 'ack to their source to findthe optic disc

0( Con>unctivae< Sclera< and Cornea"

? Ea+ine for redness< dilated or 'roken 'loodvessels< >aundice< or epider+al da+age @e(corneal a'rasions

:( Eplore"

? Look around at other parts of the fundus to findother land+arks< such as the +acula( $'serve the+ain 'ranches of the vessels for signs of nicking(Also look for any other a'nor+al changes such aspapillede+a or intraocular he+orrhaging(

:( Anterior cha+'er"

? Ea+ine the iris< pupil< lens< and anteriorcha+'er for pro'le+s such as non?reactivity<cataracts< other densities< 'leeding @e(hyphe+a< or narro# angles


$phthal+ology is perhaps the +ost specialied of specialties that you #ill rotate through in yourthird year( Much of the kno#ledge gained during this rotation #onDt arise or apply freFuently inother fields< and if they do< it #ould 'e epected that a referral to ophthal+ology #ould 'ereFuired any#ay< rather than resolving the pro'le+ #ithin your o#n specialtyDs epertise(Ho#ever< this is not to say the learning and infor+ation of this rotation should 'e ignored<

neglected< or forgotten( 8ather< as it +ay 'e the only focused eperience #ithin the real+ of theeye that students #ill get during their +edical careers< they should ensure they spend the ti+e totruly co+prehend the diagnosis and treat+ent of +any co++on eye conditions such as cataractsand glauco+a( %urther+ore< strong skills in a direct ophthal+oscope ea+ is critical fordetecting signs of other diseases such as hypertension and dia'etes< and thus the +ore practicestudents can get during the rotation the 'etter( They say the eyes are the #indo#s to the soul< 'utin +edicine< perhaps theyDre +ore #indo#s to oneDs health.





!er+atology

*ritten 'y Aaron Gropper and Andy Chen< M! /6),Edited 'y La#rence Haiducu< M! /6)0

HE B7G 47C U8E" 7& 8$!UC 7$&

!er+atology is a ) #eek rotation and is interchangea'le in the schedule #ith opthal+ology<another ) #eek rotation( 7t focuses on the skin and associated structures and enco+passesencounters #ith 'oth very co++on skin conditions @e( acne< as #ell as possi'ly rarer diseases@e( Steven?=ohnson syndro+e( Although it is short in length< it is very fast?paced and is >a++ed #ith a +ultitude of clinics covering various areas of der+atology( 7t is a very en>oya'lerotation< and students #ill gain a key revie# of the integu+ent 'lock fro+ /nd year(


Most days start at 2a+< 'ut students #ill need to call each +orning clinic the day 'efore toconfir+ the start ti+e #hen the first patient is 'ooked( Clinics are only a half day long< and inthe afternoon students can either epect to 'e at another clinic @confir+ the start ti+e in advanceas #ell< or on a der+atology consult call service( Afternoon clinics typically end around 0",6 'ut< again< this varies depending on #hen the last patient is scheduled( The der+atology resident#ill release the student fro+ consult call duties around 0",6p+(


There is no overnight call during this rotation( Students +ay< ho#ever< 'e asked to see hospital

consults during the day if they have no clinic scheduled( These can then 'e revie#ed #ith theresident or staff(

HE GEA8" *HA $ B87&G 9 CA88-

A pocket guide #ith der+atology pictures and infor+ation is helpful during the rotation(Si+ilarly< a s+artphone #ith an app or internet access can 'e used as a reference source( As

al#ays< a pen< paper and clip'oard are essential( Students +ay also 'e epected to #ear their#hitecoats during this rotation< depending on the preceptorDs preferences( Students should alsore+e+'er to have +ultiple copies of the evaluation for+ #ith the+ at all ti+es< as they #ill

reFuire one to 'e filled out 'y the preceptor after each clinic @+ore for attendance purposes thananything else( These for+s should then 'e su'+itted to the 3GH resident at the end of the#eek(




Me+ora'le Mo+ents

*hen 7 think of der+atology< 7 tend to envision rashes< lesions andfancy cars( This is not #hat 7 got on +y first consult in der+atology( 7t#as +id?+orning at Saint 4aulDs Hospital #hen +y resident asked +eto see a patient recently ad+itted to e+erg( He #as a patient in hisfourties #ith no fied address and a history of drug and alcohol a'use($n ea+< his 'ody #as covered #ith ecoriations and lichenification(

The rash #as unlike anything 7 had seen in %itpatrickDs( Afterdiscussing +y findings #ith +y resident< 7 #as encouraged to check thesee+s of his clothes 'ecause so+eti+es you can spot the eggs of sca'iesin the see+s( Upon insepection< 7 could not find any eggs P 'ut thesee+s #ere cra#ling #ith live 'ugs(


7 have a passion for the arts( There isnothing +ore relaing and re#ardingfor +e than to catch a play or a ne#

ehi'it at one of our #onderful+useu+s( Clerkship is stressful( %or

+e< allo#ing +yself to still indulge in+usic< theater< art#ork and the like is

an escape that helped +e through+edical school(


4A 7E& S A&! $ HE8 7&%$

As students are +oving fro+ clinic to clinic< they #ill not need to keep careful track of patientdetails( *riting on and referring to the chart papers should 'e sufficient #hen revie#ing #ithstaff( Students should ensure they have read the orientation package to learn ho# to take ader+atological history and physical in order to #rite a proper consult(


The online UBC der+atology #e'site and +odules are a great resource( Students should alsoread the provided reading +aterials @e( The %unda+entals of Skin !isease Therapy< prior tothe start of the #eek( As this rotation is only a #eek long< there is unlikely to 'e sufficient ti+e to

read full tet'ooks on der+atology( 7nstead< if students need to find pictures of der+atologicalconditions to fa+iliarie the+selves #ith their appearance< there are useful der+ atlases availa'leonline"

http"der+atlas(+ed(>h+i(eduder+

http"der+is(+ulti+edica(deder+isrootenho+einde(ht+


8$ A 7$&

Students should revie# co++on skin conditions prior to the start of the #eek @see The ListD

'elo#( After each day< students can also study in +ore detail any conditions they encounteredin clinic during the day that they are less fa+iliar #ith< or Fuestions that arose fro+ these cases(By the end of the #eek< students should 'e kno#ledgea'le on the +a>ority of the co++on skin

conditions< and 'e fa+iliar #ith +any other less freFuently seen der+atological diseases(


http://dermatlas.med.jhmi.edu/derm/

http://dermis.multimedica.de/dermisroot/en/home/index.htm

http://dermis.multimedica.de/dermisroot/en/home/index.htm)

http://dermatlas.med.jhmi.edu/derm/

http://dermis.multimedica.de/dermisroot/en/home/index.htm

http://dermis.multimedica.de/dermisroot/en/home/index.htm)



GE 7&G 47M4E!" *HA HE !$C $8S E&! $ AS

Students should 'e prepared to descri'e a lesion using appropriate der+atological ter+s @see TheListD 'elo#< and to co+e up #ith a differential diagnosis 'ased on the +orphology and historyof the lesion( Although students arenDt usually epected to for+ulate a treat+ent+anage+entplan< they can often learn +ore 'y thinking a'out this the+selves first< then presenting their ideasto the preceptor during the discussion( !octors +ay also ask students various details related toco++on skin conditions @e( J#hatDs the differentiating Fualities 'et#een ece+a and psoriasisIK

HA&!S $&" 48$CE!U8ES -$U GE $ !$ 7& H7S 8$ A 7$&

As the clinics are fast?paced< students +ay not have +uch chance to perfor+ any procedures<even under supervision( 7f students are fortunate< they +ay 'e a'le to perfor+ cryotherapy< skins#a's< and skin 'iopsies(


L7EL- GE !U87& G H7S 8$ A 7$&

Although there are no strict rules regarding #hat procedures students +ust do during therotation< they are epected to see +ost of the co++on skin conditions(


8evie# the online Medicol der+atology +odules fro+ /nd year< and pay attention in clinicsduring the #eek( Coupled #ith so+e 'rief revie# of the various ecellent files and resourcesavaila'le< there shouldnDt 'e any issues as the ea+ is very straightfor#ard(

HE %7&AL B$SS" E&! $% 8$ A 7$& EAMS

The Jea+K is availa'le online as a )6 +odule Fui< each consisting of : Fuestions for a total of:6( 7t can 'e co+pleted any ti+e during the #eek of the rotation< and is open 'ook. 7t #ould 'esurprising to anyone< including the faculty< if any student #as to fail this ea+(((

HE MA4" S7 E S4EC7%7CS %$8 HE 8$ A 7$&


Site

3ancouver General Hospital @3GH and St( 4aulDs

Hospital @S4H

Here is #here students

have +et on day one in

the past(

Students #ill have a clinic the first +orning< and thus should havecalled the previous #eek to confir+ the start ti+e(

)) The CLE8SH74 GU7!E ; 8otations




'elongingsI

Students +ay 'e a'le to put their things in the der+atology li'raryon the ,rd floor of the skin care centre< although it isnQt very secure$ther#ise< they can >ust leave their 'ag #herever the doctor or

M$A says is ok in the clinic(

*hat kind of teaching

or acade+ic sessions

are thereI

There #ere so+e der+atology rounds and teaching sessions #iththe resident at noon ti+e( Topics vary fro+ #eek to #eek< 'ut aregenerally interesting and useful for students to attend if possi'le(

Unfortunately food is not usually provided at these rounds(



this specialtyI

Since there is no student choice as to #hich site they #ill 'e at andthis rotation is only a #eek long< students interested in der+atologyas a future career +ust select +ore der+atology electives in 0thyear( 7n general though< 'oth 3GH and S4H provide a goodeperience for any student to learn and revie# their der+atologykno#ledge and skills(

*hat are co++on

pro'le+s patients at

this site haveI

The #eekDs eperience and patient pro'le+s encountered variesfro+ student to student< as there are different schedules #ith

different clinics assigned( So+e students +ay have various generalder+atology clinics< a BCCH pediatric clinic< a hair clinic< a rapidaccess care clinic< a skin cancer clinic< a MohDs surgery clinic< orany co+'ination of these and +ore(

HE L7S " )6 H7&GS $ &$*

: co++on der+

conditions

: ele+ents to descri'ing a skin lesion

)( Acne

" openclosedco+edones that areinfla++edR related to4roprioni'acteriu+

)( 4ri+ary lesion

"+aculepatch< papuleplaFue< noduletu+or< vesicle'ulla< pustulecyst< #heal< 'urro#< co+edone< telangiectasia< petechiaepurpuraecchy+osis< +iliu++ilia< keloidhypertrophic scar

/( Ece+a " Jthe rash thatitches< and vice versaK

/( Secondary lesionassociated characteristics" scale< crust< ecoriation< lichenification< +aceration< fissure< erosionulcer< alopecia< atrophy< oe'neriation< pathergy

,( UrticariaHives " can 'e allergic< drug related<viral< or idiopathicR oftenself?resolving

,( Appearance @colour< shape< teture "erythe+atous @red< violaceous @purple< pig+ented @'ro#n< 'lack<grey< variegated @+ulti?coloured< hypode?pig+ented< yello#<orangeR +argins @s+oothirregular< #ellpoorly de+arcated<polygonal< targetoid< u+'ilicated< verrucous

0( 4soriasis

" scaly< #ell?de+arcated< sal+on?colorplaFues

0( Configuration

"linear< annular @circularring?shaped< arcuate @curved< polycyclic<reticulate< grouped< osterifor+der+ato+al

)/ The CLE8SH74 GU7!E ; 8otations



:( Alopecia areata "patchy hair loss #ithoutkno#n cause

:( Location!istri'ution " 'ody part< fleuraletensural surfaces< sy++etry 'ilaterally<localiedgeneralied< relation to #orn o'>ectseposed skin


!er+atology is a short rotation< 'ut offers +uch in the #ay of learning opportunities( The skinis a critical organ in +aintaining health and ho+eostasis< and any 'ranch of +edicine #ill haveso+e relation to the integu+ent( Although +ost of the patients you #ill encounter #ill haveco++on skin conditions #ith a relatively standardied treat+ent protocol< there are al#ays s+allnuances to the care and +anage+ent that can only 'e appreciated through o'servation anddiscussion #ith a der+atologist( The rotation also presents a chance for you to see very uniFueskin conditions( !uring these opportunities< you should carefully o'serve and learn< as you +aynever encounter the+ again( 8egardless of your future interests< the der+atology rotation offersa fun< relaed #eek for all students #ho are keen to learn(


), The CLE8SH74 GU7!E ; 8otations



4sychiatry

*ritten 'y Aaron Gropper and Andy Chen< M! /6),

Edited 'y =ulie Man and La#rence Haiducu< M! /6)0

HE B7G 47C U8E" 7& 8$!UC 7$&

4sychiatry is a 1 #eek rotation at one of 1 Greater 3ancouver hospital sites @ora+loopselo#na< during #hich 'oth inpatient and outpatient care is integrated( Students #illeperience aspects of 'oth adult and child psychiatry in a variety of settings including patient#ards< clinics< and the e+ergency depart+ent( 3arious co++on and unco++on psychiatricconditions #ill 'e encountered< including +ood< aniety< psychotic< and personality disorders(Students #ill vastly i+prove their phar+acology kno#ledge to 'eco+e adept at psychiatric+edication use< as #ell as understanding patient +anage+ent using the 'iopsychosocial +odelof care(

Although so+e +ay regard psychiatry as a softD specialty of +edicine< consisting of all talk andlittle actual +edicine< this is far fro+ the truth( 4sychiatrists train for : years of residency in orderto fully understand the depth and 'readth of psychiatric conditions< to 'eco+e eperts in thesu'tle nuances of each +edication in a given drug class< and +ost i+portantly< to hone theirintervie# skills to the point #here they can truly understand the psychiatric patient( Studentsshould enter this rotation #ith a respect for these skills< as it #ill increase en>oy+ent and learningthroughout their 1 #eeks( Surgery +ay 'e a dissection of the 'ody< 'ut psychiatry is a dissectionof the +ind.

Me+ora'le Mo+ents

Being on call in psychiatry can 'e a+ong the +ost interesting eperiences ofyour third year( 7 can recall intervie#ing patients #ith #ild psychoses< +aniaand schiophrenia( But 'e careful and +ake sure not to 'elieve everythingyou hear like 7 did as a naive +edical student( $ne night< a young +anpresented to e+erg co+plaining of suicidal ideation( He #as #ell dressed#ith a fashiona'le sno#'oard >acket and hair that #as +essy P 'ut >ust theright a+ount of +essy and held tightly 'y hair product( He stated that he had

'een up for the past #eek 'inging on cocaine and if he #ere to leave the E!he #ould likely $! and kill hi+self( He needed to 'reak the cycle and stay ine+erg( 7 felt 'ad for the +an and tried to convince +y attending to ad+it

hi+< #hich she eventually did( Ho#ever< 7 sa# the +an on t#o differentoccasions #hen passing through the psych ad+itting #ard( *hat 7 found outlater #as that he #as a regular< often looking for a place to sleep and a +eal(Although it takes a certain a+ount of desperation to check yourself into thepsych depart+ent for roo+ and 'oard< re+e+'er to not 'elieve everythingyou hear(

Life $utside of

Medicine

More than any other rotation<psychiatry proves that there is lifeoutside of +edicine( 7 a+ an avidtennis played and as luck #ould

have it< so #as +y preceptor($nce he found out a'out +y loveof the ga+e< he +ade a point of

finding ti+e for us to play at least

once a #eek( *hile everyone else#as dogging it on the #ards< 7 #a

en>oying an hour of purerelaation.





The schedule depends on the place+ent location 'oth in ter+s of #hich hospital and #hatservice the student is on( Certain services< such as 4AU @4sychiatric Assess+ent Unit or psyche+ergency< have +ore regular hoursR other assigned attendings +ay 'e part of the consultationliaison tea+< and thus the hours @and #orkload +ay vary fro+ day to day( Typically< the averageplace+ent should epect to start at #ork at a+ and end around :p+( !epending on thepreceptor< students +ay leave early or stay until 5p+( 7n a given day< students +ay o'serve

intervie#s #ith the doctor< or actually see patients and +anage the #ard patients relativelyindependently( Students typically #ill intervie# ne# patients< round on ad+itted patients< attendfa+ily and interdisciplinary +eetings< co+plete dictations< and participate in teaching sessions(


Call hours vary 'et#een hospital sites 'ut are generally :p+?))p+ on #eekdays and start 2?a+and end at 1 or ))p+ on #eekends( 4ediatric call is on #eekends 'et#een 2",6a+ and ))a+(The nu+'er of call shifts depends on oneDs place+ent and can range fro+ no call to 5 call shifts(!epending on the site< there +ay 'e the option of 'eing off?site as long as students are #ithin a

reasona'le distance to return for patient assess+ents and< if the call shift is Fuiet< the resident+ay 'e happy to let students go early( Generally< call shifts involve assessing ne# patient consultsreferred through e+ergency to triage the urgency of +anage+ent reFuired( There +ay also 'e#ard calls for inpatient +anage+ent< 'ut generally the psychiatry nurses are very co+petent at+anaging co++on issues as appropriate orders #ould have already 'een provided through theinitial ad+ission and daily rounds(

HE GEA8" *HA $ B87&G 9 CA88-

Students #ill not need to 'ring +uch< and this is one rotation #here one #onQt need a

stethoscope( Bring along so+e notepaper< a clinical hand'ook such as Current ClinicalStrategies" 4sychiatry< and a drug reference such as Tarascon 4ocket 4har+acopoeia or 8 %ilesfor looking up psychiatric +edications( Most i+portantly< donDt forget a pen @or t#o or three.


4A 7E& S A&! $ HE8 7&%$

Each student #ill 'e assigned to see a preceptorDs patients on the #ard and can epect to +anage0?2 patients at a ti+e( The 'est #ay to keep track of patients is to +aintain a personal day sheetto record any changes in sy+pto+s< +edications< patient concerns and +anage+ent plan foreach day( !epending on the preceptor< one +ay also do consults and therefore should docu+entthe sa+e ite+s in oneDs o#n day sheet( Because histories can 'e very etensive< take notes on aseparate piece of paper and donDt rely strictly on +e+ory.

): The CLE8SH74 GU7!E ; 8otations




%irst Aid is a very popular resource to cover the 'asic kno#ledge and info( Toronto &otes< &MSand Blueprints are also popular depending on the level of detail one reFuires( 7n order to preparefor the ea+< do Fuestions ? lots of the+. Both Lange and 4retest are ecellent choices forpractice( 8eading the actual !SM is not reco++ended as an effective +ethod of studying< as itis too detailed and dense for practical student use( 7nstead< use it to look up specific criteria fordiagnosis< or #hen there is confusion after reading revie# 'ooks( $ne should also ensure that

one has learned< in detail< at least /?, co++only used +edications in each psychiatric drug class(


8$ A 7$&

8ead around patient encounters in order to develop a strong understanding of their diagnosis<issues related to it< and appropriate +anage+ent( 8ecalling patients as case ea+ples #ill help#hen asked a'out a psychiatric condition in the future( Students should devote ti+e each day toreading a'out specific psychiatric disorders or drug classes( 7deally< 'y the ti+e ea+s co+earound< students #ill have a fa+iliarity #ith the general pictureD of a patient #ith psychiatric

condition JK< the +ain diagnostic criteria< and the initial and long?ter+ +anage+ent( Anotherlarge co+ponent of learning in psychiatry is discussions #ith attendings and residents( $'servetheir intervie# +ethods and Fuestions< and use every chance availa'le to ask Fuestions and talka'out #hat the patient +ay have< and #hat to do a'out it(

GE 7&G 47M4E!" *HA HE !$C $8S E&! $ AS

4sychiatrists usually ask a'out 'asic !SM criteria for +a>or diagnostic groups such as +ooddisorders< psychosis< and personality disorders< and #ill often have students give their differentialdiagnosis using the +ulti?aial diagnostic for+at( !rug classes< their side effects< +onitoring

para+eters and dosing options can also 'e Fuied( Students should also kno# ho# to inFuirea'out specific sy+pto+s< and #hich are +ost i+portant for a given illness( $verall< psychiatry isa relatively relaed at+osphere< and the doctors donDt tend to grill students intensely @phe#.<though students should still 'e prepared to ans#er Fuestions(

HA&!S $&" 48$CE!U8ES -$U GE $ !$ 7& H7S 8$ A 7$&

The only +a>or @and reFuired procedure to o'serve and assist #ith in this rotation iselectroconvulsive therapy @ECT( !o utilie the opportunity to learn a'out ECT< its 'enefits andrisks< and its +ethods< as it is an uniFue chance to see one of the +ost effective treat+entsavaila'le to psychiatry( There still re+ains a lot of stig+a around ECTR during the rotation oreven in future practice< this topic +ay arise again fro+ patients or opponents to the procedure(





L7EL- GE !U87& G H7S 8$ A 7$&

Students should have no difficulty seeing the +ost co++on psychiatric disorders such asdepression< aniety and schiophrenia( There should also 'e a+ple opportunity to o'serve other+ood disorders @e(g( 'ipolar< psychoses @e(g( schioaffective< and neurological function deficits@e(g( de+entia and deliriu+ at least once or t#ice( Ho#ever< there +ay 'e a s+aller chance ofo'serving conditions such as personality disorders< sleep disorders or drug overdoses< as these are

+ore co++only +anaged in the outpatient setting(


There are +any options in ter+s of ea+ preparation< and each has its +erits< #hether studentsprefer to read revie# 'ooks throughout the rotation< to learn around their patients andsupple+ent +issing infor+ation< or to do nothing 'ut practice Fuestions until they are adept atrecogniing psychiatric disorders 'ased on the patient description(

The +ost likely pitfall of students in psychiatry is neglecting the ea+s altogether 'ecause they

epect the+ to 'e easy( Although this &BME +ay 'e the easiest of the : due to the nature of thespecialty and the +ore focused 'readth of kno#ledge< students should not epect to #ingD theea+ and cruise through( 4sychiatry reFuires a strong grasp of phar+acologic treat+entoptions< including 'enefits< risks< and side effects of +edications( There are also su'tle nuancesof diagnosis that differentiate 'et#een disorders( !o &$T leave studying to the last +inute.

A steady pace of reading throughout the rotation #ill allo# for a +ore relaed and funeperience< and prevent ea+ aniety during the last #eek( Mentally revie# patientsencountered throughout the #eeks to use as case ea+ples of +anage+ent< and the days prior tothe ea+s< repeatedly revie# the classes of psychiatric +edications until at least )?/ different

drugs per class are +e+oried< as #ell as ho# to use the+ appropriately in the treat+ent ofconditions(

HE %7&AL B$SS" E&! $% 8$ A 7$& EAMS

The psychiatry ea+s consist of an &BME and a clinical reasoning ea+ @C8E< 'oth occurringon the last day of the rotation( There is no $SCE(

The &BME ea+ is a standard )66 +ultiple choice Fuestion ea+ that is provided 'y theA+erican &ational Board of Medical Ea+iners< to 'e co+pleted in a span of / hours :6+inutes( 16 or greater is reFuired to pass the ea+( Each Fuestion typically consists of a

patient vignette illustrating a presenting case #ith associated investigations and results< follo#ed 'y a clinical Fuestion #ith @usually : +ultiple choice selections( The Fuestions are nota'lylonger reads than previously encountered MC Fuestions fro+ )st and /nd year +edicine ea+s<and have 'een kno#n to contain etraneous or ecessive details not reFuired to ans#er theFuestion( As such< it is reco++ended that ea+inees first gli+pse #hat the Fuestion is asking<then read Fuickly through the vignette 'efore providing oneDs 'est ans#er and +oving on to thenet Fuestion( Ti+e can 'e lacking if every Fuestion is read +eticulously and overanalyed.




The C8E is a , hour #ritten ea+ consisting of 1 separate case?'ased Fuestions< #ith t#o ofthe+ 'ased on videos of patient intervie#s #atched during the ea+ period( $ne of the videoFuestions #ill ask the student to #rite a full +ental status ea+ 'ased on the intervie#< and theother is related to a diagnosis and +anage+ent plan of the intervie#ed patient( $ne of there+aining 0 Fuestions #ill 'e related to child psychiatry< and the rest of the ea+ Fuestions #illeither ask for"

)( A +ulti?aial differential diagnosis of the patient case< identifying the leading

diagnosis and

>ustifying oneDs choices( Students should 'e a'le to identify

diagnostic criteria that point to#ardsone disorder over another in their

>ustification< the various social?environ+ental factors that pose

a pro'le+ #ith

patient +anage+ent< and also #hat the GA% score they assign the patient

+eansin relation to patient +anage+ent @e(g( certification reFuiredI

/( A co+plete 'iopsychosocial +anage+ent plan for the patient case< #ith short and long?ter+

treat+ent options and epectations( !onDt forget to consider factors such as patient safety @e(g(

need for hospitaliation or certification and o'taining collateral info @e(g( fro+ past records<fa+ily< friends< and case +anagers(

See the psychiatry section of the docu+entation chapter @p( 0:< for eplanations of ho# to #ritea MSE< +ulti?aial diagnosis< and 'iopsychosocial +anage+ent plan(




HE MA4" S7 E S4EC7%7CS %$8 HE 8$ A 7$&

To find out #here to go on the first day< CHEC -$U8 EMA7L for a +essage fro+ the depart+ent( Listed is#here students have +et on day one in the past(

S it e H er e i s #h er e

students have +et

on day one in the

past"

*here can 7

store +y

'elongingsI

*hat kind of

teaching or

acade+ic sessions

are there at this

siteI

7s this a good site

for so+eone

interested in this

specialtyI

*hat are co++on

pro'le+s patients

at this site haveI

*hat is the call

schedule likeI

3GH Students #ill 'ee+ailed a'outregarding +eetinglocation and ti+e(

Storage dependson the psychiatricunit or locationyou are assignedto(

8esident teaching isfro+ ,?0p+ on%ridays( There arealso child psychiatrylectures *ednesday+ornings at BCCH(

This is a good option forany student interested inpsychiatry< as they #illsee +any co++ondisorders(

This depends on#hich unit you areassigned to< as certainsettings +ay encounter+ore psychosispatients< #hereas theshort?stay assign+ents+ay see +oredepression and anietycases(

There areapproi+ately 5 callshifts during therotation< #ith /#eekend call shifts@2",6 a+ to )) p+(&or+al #eekday callshifts span fro+ :?))p+(

S4 H Students #ill +eetthe site coordinatoron the first day in thepsychiatry 'uilding

for orientation(

Storage dependson #hich #ardyou are assignedto< 'ut typically

are put at thenursing stationon the #ard(

The chief psychiatryresident #ill provideteaching( There arealso child psychiatry

lectures *ednesday+ornings at BCCH(

This site is a great optionfor students interested inpsychiatry< especially ifthey #ish to see a greater

proportion of psychosisand su'stance?induceddisorders(

4sychosis is the +ostco++on conditionpatients have at thissite< and thus students

should 'eco+e #ellversed in theevaluation and+anage+ent of thisgroup of disorders(

The call rotatedthrough MS7sassigned to differentlocations< #ith the

option to trade #ithpeers( *eeknights gountil ))p+ or+idnight( *eekendsare fro+ 2a+?))p+ 'ut often can 'e donefro+ ho+e if studentsare not too far a#ay(



S it e H er e i s #h er e

students have +et

on day one in the

past"

*here can 7

store +y

'elongingsI

*hat kind of

teaching or

acade+ic sessions

are there at this

siteI

7s this a good site

for so+eone

interested in this

specialtyI

*hat are co++on

pro'le+s patients

at this site haveI

*hat is the call

schedule likeI

8CH The first day starts#ith an orientationsession #ith the chiefresident in psychiatryin the Sher'rooke

Centre @the +ainpsychiatry 'uilding(7nstructions #ill 'ee?+ailed regarding+eeting ti+e andlocation( Theresident #ill givestudents a tour of8CH< including theunderground tunnelsto get to the +ainhospital 'uilding< theresidentstudentlounge< andintroduce the+ to the

#ards 'efore startingthe first day #ith theattendings(

-ou can put yourlock on any openlocker in the callroo+s area< aslong as you let

Leila Bailey@+edical studenteducationcoordinatorkno# #hichlocker youDve putyour lock on

There are #eeklychief residentteaching sessions on*ednesday+ornings for )?/

hours( 3arious lunchhours throughout the#eek< there are alsogrand rounds< caserounds< residentSTACE8intervie#ing practicesessions< and=eopardy revie#rounds. Childpsychiatry lecturesare videoconferencedfro+ BCCH every*ednesday +orning(

This is a nice option forany student< #hetherthey are interested inpsychiatry or not< asthere is a good 'alance

of disorders that presentto 8CH< and the psyche+ergency unit is alsoFuite 'usy( 7f a studentis +ore interested inoutpatient or childpsychiatry< ho#ever<8CH doesnDt offer as+uch eperience in theseaspects(

!epression<schiophreniapsychosis< 'ipolar disorder areco++onlyencountered a+ong

inpatients and throughthe psychiatrye+ergency unit(

There are , call shiftstotal< #ithapproi+ately one#eekday< one %ridayand one #eekend

shift< 'ut these arerelatively flei'le andcan 'e s#itchedaround if one asks thechief resident( The#eekdays #ill 'e fro+:?))p+ only< #hile#eekends are 2a+?:p+< though you +aystay later as needed(

LGH

8GH

SM H

-ou #ill receive ane+ail prior to yourrotation infor+ingyou #here to go onyour first day(

A locker #ill 'eassigned to you(

Most acade+ics arecovered in the first#eek( ChildrenDspsychiatry teachingoccurs once a #eek(

S+aller patient variety 'ut increased interaction#ith your preceptor(



HE L7S " )6 H7&GS $ &$*

: categories of psychiatric

disorders

: classes of +edicationstreat+ents

)( +ood disorders"

depression ? M!E< dysthy+ia

'ipolar ? type ) @+anic and / @hypo+anic

)( anti?depressants"

SS87 ? fluoetine< paroetine< fluvoa+ine

S&87 ? @desvenlafaine< duloetine&!87 ? 'uproprionSA87 ? traodoneTCA ? a+inor? triptyline< clo+ii+i? pra+ine

/( psychotic disorders"

'rief psychotic episode @[) +onthschiophrenifor+ @[1 +onthsschiophrenia @_1 +onthsschioaffective @at least / #eeks of

psychosis #ithout affective co+ponentdelusional disorder

/( anti?psychotics"

typical ? haloperidol< loapine< thioridaineatypical ? cloapine< olanapine< Fuetiapine< risperidone< paliperidone< aripipraole

,( aniety disorders"

generalied aniety disorder @GA!social aniety X? agorapho'iaspecific pho'ia ? ani+al< environ+ent<

'lood?in>ection in>ury< other o'sessive?co+pulsive disorder @$C!post?trau+atic stress disorder @4TS!

,( aniolytics and sedatives"

'enodiaepines ? loraepa+< diaepa+< clonaepa+ @good for GA!anti?psychotics ? haloperidoltraodone

0( personality disorders"

cluster A" paranoid< schioid< schiotypalcluster B" anti?social< 'orderline< histrionic<

narcissisticcluster C" avoidant< dependent< o'sessive?

co+pulsive personality disorder @$C4!

0( +ood sta'iliers"

lithiu+ ? +onitor levels @6(1 ? )(/ $< renalfunction< and toicity sy+pto+s

divalproevalproic acid ? +onitor levelsatypical anti?psychotics ? risperidone<

olanapine< Fuetiapinela+otrigine and car'a+aepine

0( su'stance use disorders"

tolerance vs dependence vs addiction:( therapy +odalities"

electroconvulsive therapycognitive 'ehaviour therapyinterpersonal therapypsychoanalysiseposure and confrontation therapy

/6) The CLE8SH74 GU7!E ; 8otations




4sychiatry is a rotation #here +ost students +ay have no idea #hat to epect( Ho#ever< +anystudents co+plete it #ith ne#found appreciation for the skills and eperience possessed 'ypsychiatrists that are necessary to fully engage and understand their patients( There are +anyco++onplace disorders and conditions @e(g( depression that can act as co+or'idities for patientsin all specialties< as #ell as a fe# uniFue disorders that +edical students #ill only have theopportunity to see during this rotation(

Students #ho start their psychiatry rotation #ith an open +ind and a keen +otivation to learn allthey can a'out this specialty #ill learn far +ore< and #ill garner the appreciation of theirpsychiatry attendings and residents( Students #ho continue to regard psychiatry as a pointless or+enial part of their clinical training +ay survive the 1 #eeks and pass the ea+< 'ut they #illlikely 'e less satisfied than their enthusiastic colleagues(

By the end of the rotation< students #ill ideally have vastly i+proved their intervie#ing andco++unication skills< and have seen at least a fe# patients or diagnoses that are unlike anythingpreviously encountered( 8egardless of the disorder< every patient in psychiatry has a life story<

the details of #hich are pieces of the pule that one +ust co+plete to find a correct diagnosis(


/6/ The CLE8SH74 GU7!E ; 8otations



hird -ear Elective

*ritten 'y Leslie Anderson< M! /6),

!uring third year< you #ill have a / #eek elective during #hich you can do pretty +uch anything

you #ant( There are good instructions for applying for your elective on Medicol< so this section#ill focus on so+e of your options and a fe# tips for +aking the +ost of the t#o #eeks(

The third year elective is the only ti+e during +edical school #here you get a chance to do#hatever you like #ithout having to go through an accredited university to apply for an officialelective( -ou +ust have a physician preceptor #ho has agreed to oversee your perfor+ance and#rite an evaluation at the end< 'ut aside fro+ that condition< you can choose #hatever you#ould like to do as long as it relates to +edicine(

So+e people do opt to do a clinical elective in order to try out a specialty they havenDteperienced yet< or to visit a progra+ they +ight 'e interested in applying to( *hile students arediscouraged fro+ using their third year elective as a Ca8MS specialty JauditionK period< aclinical elective +ight 'e a good option if youDre thinking a'out a specialty that you #onDt rotatethrough during third year @e(g( radiology< pathology< physiatry< etc( or if you #ant to do aco+petitive specialty and #ish to visit a progra+ to +ai+ie your chances of +atching to thespecialty @e(g( plastic surgery< ophthal+ology< der+atology etc(( -ou +ay have 'etter luckorganiing an out?of?province clinical elective< since at UBC< the fourth year students get priorityfor clinical electives< so the specialty you #ant +ight not 'e availa'le(

7f you donDt fit into the categories +entioned a'ove< use your elective to do so+ething fun andinteresting that you #onDt 'e a'le to do as an elective in fourth year( -ou could go international

and do so+e volunteering that isnDt through a specific university progra+< attend a yoga retreat<do so+e training in cognitive?'ehavioral therapy< finish up a research pro>ect< learn sign language<or do outreach #ork in the do#nto#n east side( The sky is the li+it< as long as you can relate#hat youDre doing to +edicine and you have a physician to oversee you( Try to think outside the 'o and take advantage of this opportunity(

Set up your elective as early as possi'le to allo# for any co+plications or changes< and send inyour application early @itDs due at least 0 #eeks 'efore your elective starts to +ake sure you haveti+e to co+e up #ith an alternative in case your elective isnDt approved( -ou #ill also have to#rite a short essay reflecting on your eperiences during your elective< so you +ight #ant to keep

a >ournal over the t#o #eeks to have notes to >og your +e+ory(

Make use of this opportunity to have so+e fun #ith +edicine< especially since third year has itsshare of ehausting and frustrating +o+ents.

/6, The CLE8SH74 GU7!E ; 8otations



Me+ora'le Mo+ents

Elective P Anato+ical 4athology

My interest in anato+ical pathology @particularly forensic pathology andautopsy lead +e to do +y / #eek elective in pathology to +ake sure that 7en>oy the day?to?day activities 'efore 7 co++it to it as a career( 7 opted to go

out of province to a city #here the cri+e rate #as such that 7 #as pretty+uch guaranteed a ho+icide autopsy #hile 7 #as there( 7 #as notdisappointed. $n the last day of +y rotation< a +urder victi+ #as 'rought in( The police#ere in attendance< as they are #ith any forensic autopsy< and since 7 had hadti+e to earn the trust of the pathologist< 7 #as allo#ed to assist( 7 +easuredeternal #ounds< dre# up fluids for toicology< and recorded organ #eights(As #e proceeded< #e realied #e #ould need the +urder #eapon in order toco+pare the in>uries #e found #ith #hat allegedly caused the+( A policeofficer #as sent to pick the #eapon up fro+ the police station< and +uch to+y delight< the pathologist suggested 7 go #ith hi+. 7 cli+'ed into the police van and #e headed off( $nce #e arrived at the

police station< 7 got to go in #ith the officer and into the evidence locker( *efound #hat #e #ere looking for P the +urder #eapon< in an oversiediploc?style 'ag P and headed 'ack to the hospital( 7 strutted through thehalls in +y scru's< flanked 'y a police officer carrying an evidence 'ag< and 7#as practically glo#ing #ith ecite+ent( 7 felt like 7 #as on CS7.&o other eperience in +edical school has energied +e Fuite like that day(

7 had found +y specialty.

Life $utside of

Medicine

-our third year elective can 'e ati+e to eperience a different

specialty or focus on studying fora difficult upco+ing rotation(

Ho#ever< it can also 'e a ti+e torecover 'y choosing a light

#orkload and +aking rest andrelaation your priority( !onDt feeguilty a'out doing so( As long as

you are learning so+ethingduring your elective< you are

successful( 7f you can co+e 'ackfro+ your elective recharged< even

'etter(


/60 The CLE8SH74 GU7!E ; 8otations



-EA8 %$U8"

ELEC 73ES 9 CA8MS

Co+piled 'y Clara *est#ell?8oper @M!4h! 4rogra+

$vervie#(((( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( /61

Electives((( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( /62

8eference Letters(((( ( ( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( /)/

Ca8MS Applications((( ( ( ( ( ( ( ( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( /)0

Ca8MS 7ntervie#s(((( (( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( /):

/6: The CLE8SH74 GU7!E ; -ear %our" Electives 9 Ca8MS



$vervie#

*$8?L7%E BALA&CE

*hile there is +uch to learn and to organie in fourth year P including travel< electives< andCa8MS P the #orkload is less intense than in -ear ,( Call is less de+anding and studying 'eco+es +ore focused< so you should have +ore ti+e for friends< fa+ily< and other interests(So+e students intentionally choose electives that are light on call< and in general find it easier to+aintain a healthy #ork?life 'alance than in previous years( Many rotations are less de+andingand +uch of your ti+e #ill 'e spent revie#ing and adding on to previously learnt +aterial( Thisis a good year to +ake etra ti+e for friends and loved ones< especially if you are travelling andfreFuently a#ay fro+ ho+e for electives(

BE&E%7 S

Benefits of fourth year include 'eing a'le to tailor your learning to topics of clinical i+portance#ithout constantly focusing on ea+s< having +ore ti+e to spend #ith friends and fa+ily< having+ore autono+y and choice in clinical electives< and #orking fe#er call shifts( -ou also have theopportunity to travel to ne# cities< spend ti+e in out?of?province hospitals to eperience ho# theyrun< and choose electives 'ased on your interests and career goals( %ollo#ing Ca8MS +atches<you can en>oy your electives #ithout the stress and uncertainty that co+es #ith the applicationprocess(

CHALLE&GES

Ma>or challenges include a potential loss of connection #ith friends and colleagues< freFuenttravel< and aniety a'out Ca8MS +atches( Try to +ake ti+e to +eet #ith friends andclass+ates< as this does not occur easily #hen everyone is doing different electives( The lead?up toCa8MS is the +ost challenging period< follo#ed 'y uncertainty prior to +atch day( eep in +indthat the vast +a>ority of people are happy #ith their +atch result< and that you really do have+ore control over the process than you think. !o your 'est to stay focused on learning andpatient careR this is often a challenge #hen you are #orking on applications or a#aiting intervie#invites or +atch results( Also keep in +ind that there is a t#o?day $SCE in +id =anuary< t#o#eeks 'efore Ca8MS intervie#s( Most people pass< 'ut you do need to prepare for this(

E4E&SES

These are highly varia'le( Many students spend N,666?:666 on travel and acco++odation<including electives and Ca8MS( eep in +ind that if you are applying to a co+petitive specialtyat a specific site< it +ay 'e to your advantage to have done an elective there and to +ake contactsat other schools(

/61 The CLE8SH74 GU7!E ; -ear %our" Electives 9 Ca8MS



-ou can save so+e +oney 'y staying #ith friends or fa+ily< taking the train or 'us 'et#eenCa8MS intervie#s @e(g( train in $ntario and 'us 'et#een Ed+onton and Calgary< and 'ookingflights #ell ahead of ti+e #hen prices are lo#er( Carpooling during the Ca8MS tour can giveyou a chance to +eet ne# people and is +ore afforda'le than the 'us< particularly in BC or$ntario @>ust ensure you are #ith good friends 'ecause the people around you can affect ho# youhandle the stress.( Take advantage of *est=et seat sales and the BCMA Club MD #e'site for hoteldeals( %ind out #ho #ill 'e in the sa+e city and try to share tais< car rentals< or hotels(

H$* $ 48E4A8E

Study hard P >ust as you have 'een doing throughout your acade+ic years. eeping your C3 up?to?date is helpful< as is keeping notes on +eaningful activities or eperiences to help as you #riteyour Ca8MS applications( !o your 'est to develop ecellent #orking relationships #ith yourclass+ates and #ith others on your tea+ during -ear , rotations( eep in +ind that you +ay usegeneral reference letters fro+ third year for your Ca8MS application< so if you have a positiveeperience #ith a staff +e+'er< do not hesitate to ask for one( Try to +aintain your interestsoutside of +edicine as #ell(

Eplore specialties early to figure out #hat interests you< and reflect on #hat it is a'out certainspecialties that appeals to you @or not( 7n first and second year< shado# in areas you think +ightinterest you< seek out +entors #ho can ans#er your Fuestions< and talk to residents a'out theirtraining eperiences #henever you can( 7f you are trying to decide 'et#een very differentspecialties< consider trying to do these rotations earlier in third year( %inally< re+e+'er that +ostpeople figure out #hat they #ant to do< even if it is at the very last +inute P you donDt al#aysneed to have a plan 'efore starting clerkship.





Elect ives

CH$$S7&G ELEC 73E S4EC7AL 7ES

Choose electives that interest you and help you cover a 'road 'ase of +edicine as you prepare forresidency( Ma>or considerations include eperiencing +ultiple progra+s< 'uilding skills toi+prove on #eaknesses< and gaining eperience that #ill 'e useful for your specialty of interest(Ask staff and residents in your specialty of interest lots of Fuestions a'out electives and #hatthey #ould reco++end(

General electives are #ell suited to a four?#eek ti+e period< #hile +ore specialied electives areoften t#o #eeks long< although this varies considera'ly( Students often choose to co+plete+ultiple t#o?#eek electives in their specialty of interest in order to visit as +any progra+s aspossi'le( Co+pleting these prior to Ca8MS deadlines #ill allo# you to eperience +ore varietyin different fields and different cities( Ho#ever< other students prefer to schedule longer electivespre?Ca8MS to provide +ore continuity and develop stronger relationships #ith preceptors #hocan provide reference letters( 7ndeed< so+e electives #ork 'etter in four #eeks< providing +oreopportunity for follo#?up and ti+e to get to kno# the staff( %ollo#ing Ca8MS< choose rotationsthat you #ill en>oy and that #ill co+pli+ent your residency choice(

7&? $8 $U ?$%?48$37&CEI

$ut?of?province electives allo# you to get a sense of #hat it #ould 'e like to live in other cities(Think of places you #ould consider ranking for Ca8MS< and also consider areas in #hich youhave friends< fa+ily< or other contacts( $ut?of?province electives also provide an opportunity to

learn a'out differences in health care and teaching across the country and to +eet residents andstaff in your progra+s of interest( Ho#ever< do not feel that you +ust do an out?of?provinceelective P so+e students choose to do as +any as possi'le and others do none at allR +anystudents hoping to +atch in?province choose +ore in?province electives in their specialty ofinterest(

Sign up for out?of?province electives early< ideally 'efore Christ+as< as it can 'e difficult to findan elective you #ant if you are looking later in the year( Consider applying for in?provinceelectives as 'ack?up in case your out?of?province electives do not #ork out(




48E4A8A 7$& A&! S U!-7&G

Most students find they spend less ti+e studying in fourth year< 'ut preparation for electives isstill i+portant( Good general resources include eMedicine< the little red'luegreen 'ook< -ear ,clerkship notes< Toronto &otes< and BC Guidelines for %a+ily Medicine( Blueprints and 8ecall 'ooks fro+ third year are also helpful( Consider preparing for an elective the #eekend 'eforeusing a general resource< and then read around at least one case each day using a +ore detailedresource such as Up?to?!ate( eep in +ind that you #ill 'e epected to kno# ho# to approach

and +anage JK if you had a si+ilar case the previous #eek(

Ti+e for studying is often li+ited during the day< especially on surgical electives< so efficiency isi+portant( So+e progra+s #ill suggest areas of focus if you ask ahead of ti+e< and +ostpreceptors and residents are happy to suggest specific resources in their area( Surgical electivesare a good ti+e to practice suturing on your o#n(

ACC$MM$!A 7$& %$8 $U ?$%? $*& ELEC 73ES

-ou can save +oney 'y staying #ith friends or fa+ily #henever possi'le( Check the housing sites

specific for the school you are visiting and ask other students #ho have co+pleted electives at thesite to #hich you are travelling( Ad+inistration at each site is often very helpful in reco++endingplaces to stay( Consider hotels or rental apart+ents< depending on your preference and 'udget Poften you +ay 'e a'le to share #ith other students( 4receptors +ay also have so+e ideas a'out#here other students have stayed in the past( Consider your proi+ity to the hospital site< grocerystores< a kitchen< and gy+ or other #orkout options(

!E A7LS $& S4EC7%7C ELEC 73ES %8$M 48E37$US S U!E& S

% a + i l y M e d i c i n e P 3 i c t o r i a @ / # e e k s (

Ecellent elective #ith !r( Chris %raser( Eposureto inner city +edicine< addiction< and deto(

% a + i l y M e d i c i n e P 3 a n d e rh o o f @ 0 # e e k s ( A+aing co++unity of G4s that providepri+ary care< e+ergency< surgical care< anaesthesia< oncology< o'stetrics< palliative and long?ter+care( A true rural and full service fa+ily +edicine eperience and so+e of the 'est care deliveredin BC(

% a + i l y 4 r a c t i c e P M a c k e n i e @ 0 # e e k s ( Clinichospitalla' all in one location<supportive co++unity< ecellent preceptors< and a +i of clinice+ergencyprocedures( Theco++unity is very active" cross?country ski #ith the docs and nurses and use the gy+ and pool atthe 8ecCentre close 'y @pass provided( An ecellent eperience if you are interested in ruralpractice( %ree acco++odation and etra funding for doing an elective in &orthern BC(


http://emedicine.medscape.com/

http://www.bcguidelines.ca/


http://emedicine.medscape.com/




% a + i l y M e d i c i n e < M a t e r n i t y P L a n g l e y @ 0 # e e k s ( An ecellent opportunity for hands?on care and for +anaging patients independently( The clinic staff are #elco+ing and treat you aspart of the tea+( The nurses in the +aternity #ard are happy to teach and include you in allaspects of care( -ou can see #o+en in the clinic< deliver their 'a'ies< and perfor+ #ell 'a'yvisits. A highly reco++ended learning opportunity if you are interested in $'sGyn< %a+ily4ractice< or 4ediatrics(

% a + i l y M e d i c i n e < M a t e r n i t y P ! u n c a n @ 0 # e e k s ( Supervisors are great

teachers+entors and provide students #ith opportunities to run the prenatal visits< perfor+procedures< and participate in deliveries( %lei'le call(

H o s p i t a l i s t P a + l o o p s @ / # e e k s ( 8oyal 7nland Hospital is a 'usy trau+a center #ithinteresting and diverse pathology( The service ad+its al+ost everyone< and other services@General 7M< Surgery< etc( largely play a consulting role( The doctors in a+loops areoutstanding and keen to teach< including E8 physicians< internists< and pediatricians( Thehospitalists< ho#ever< are the +ain reason this is such a great rotation P they function likeinternists in the hospital 'ut have diverse and interesting clinics on their off?#eeks @eatingdisorders< o'stetrics< etc(( 8eco++ended for those interested in %a+ily 4ractice or 7nternal

Medicine( &o call(

G e n e r a l S u r g e r y< & a n a i + o @ 0 # e e k s ( %antastic elective #ith staff +e+'ers #ho are keenon student involve+ent and flei'le #ith scheduling(

4 e d i a t r i c G e n e r a l S u r g e r y P A l ' e r t a C h i l d r e n Ds H o s p i t a l @ / # e e k s ( Supportive staff(Great +i of outpatient clinic and $8 ti+e( Lots of eposure to staff as there are fe# residentsRan opportunity for +ultiple reference letters(

h o r a c i c S u r g e r y P e l o # n a @ 0 # e e k s (

*ork #ith all four M!s and the &4 on the

service( 0(: days per #eek in the $8( Mini+al call( Be prepared and eager to learnR al#ays listenduring the $8 as they have a lot of eperience and +any pearls to share(

G e n e r a l 7 n t e r n a l M e d i c i n e P & e l s o n @ 0 # e e k s ( A+aing physician @!r( Malpass( Staffat elo#na General Hospital are friendly and helpful( 4athology is varied( Long days @)/h 'utno call or #eekends( This is an opportunity to learn a lot in a very supportive environ+ent(

E + e r g e n c y 4 s y c h i a t r y P 3 a n c o u v e r< 3 G H @ 0 # e e k s ( A great elective for anyonethinking of going into psychiatry( Lots of independence and responsi'ility in addition to one?on?one ti+e #ith preceptors revie#ing cases( &o call is epected 'ut consider doing at least one

#eekend call shift @)/ hours #ith #ho+ever you plan to ask for a reference letter( 7t is easy to sit 'ack and get overlooked if you donQt +ake an effort to take on patients(

E + e r g e n c y P o r o n t o < S u n n y ' r o o k @ / # e e k s ( Highly reco++ended( The attendings areecellent teachers( Huge assort+ent of presentations #ith lots of trau+a and procedures(Significant hands?on ti+e #ith fe# other learners(

/)6 The CLE8SH74 GU7!E ; -ear %our" Electives 9 Ca8MS



S p o r t s M e d i c i n e < & o r t h S h o r e @ * h i s t l e r @ 0 # e e k s ( This elective is in *histler @#hichis not clear #hen you sign up( The clinic is 'usy and not al#ays supportive( 7t is +ore fa+ily+edicine than sports +edicine?'ased( &ot reco++ended(

! e r + a t o l o g y< $ t t a # a @ / # e e k s ( Good teachingR residents are intense and focused( Lots ofo'servation #ith li+ited hands?on eperience(

$ p h t h a l + o l o g y P $ t t a# a @ / # e e k s (

Good elective despite the difficult application process(

Lots of early +ornings( Be sure to go in for clinics on the #eekend ? ask the residents a'out this(


/)) The CLE8SH74 GU7!E ; -ear %our" Electives 9 Ca8MS



8eference Letters

H$* $ AS %$8 8E%E8E&CE LE E8S

!onDt 'e afraid to ask for a letter P +ost preceptors epect that you #ill< and if you #ork hardthey are usually happy to #rite the+( -ou can al#ays choose not to use the letter< so err on theside of asking for too +any as it is often difficult to go 'ack later( 7f offered< accept a letterregardless of #hether you intend to use it or not( -ou can ask for a general or specialty?specificletter in any specialty< regardless of your area of interest(

Co++unicate clearly regarding your learning o'>ectives and your intention to apply to yourspecialty of interest( Most preceptors are very supportive( %or electives close to the Ca8MSdeadline< tell your preceptor early in the elective that you are hoping for a letter of reference< andoffer to provide an updated C3 and paragraph a'out yourself( This #ill ensure that heshe is

attentive and sees you doing enough to 'e a'le to provide specific infor+ation( Ask for regularfeed'ack so that you understand #hat your preceptor kno#s a'out your skills and co+petencies(

&ear the end of the elective< ask if heshe can provide a strong and co+petitive reference letter< 'ut provide an JoutK 'y +aking it clear that you understand if they are not a'le to do so( Ask inperson< and then follo# up 'y e+ail #ith infor+ation docu+ents fro+ $SA and any otherresources they reFuest( %ollo# up as soon as possi'le after a rotation to ensure that your letter isnot forgotten and send a thank?you once it has 'een received( $nline su'+ission is easiest(

-ou +ay find that four?#eek electives are easier for getting letters than t#o?#eek electives< 'ut 'oth are feasi'le( 4eople #ho have spent a +onth #ith you such as CTU Attendings or General

Surgery Attendings are ecellent people to ask( eep in +ind that it can 'e easier to +ake goodconnections #ith the staff outside of 'usy hospitals #here you +ay have +ore hands?onopportunities(

*H$ $ AS %$8 8E%E8E&CE LE E8S

Ask anyone #ith #ho+ you #ork #ell and esta'lish a good rapport( This includes preceptors#ho are not necessarily in a specialty to #hich you intend to apply< although referees in yourspecialty and progra+ of interest are clearly ecellent choices( Think a'out individuals fro+specific sitesprogra+s< as #ells as those #ho +ight have #orked closely #ith you in +ultiple

areas and therefore have a reasona'ly accurate all?round picture of you< particularly if you feelthat your ti+e #ith that individual highlighted your strengths( Consider individuals #ho canspeak to a particular skill set reFuired for the specialty< and think a'out #hether they #ould 'e#ell kno#n to your progra+ of interest(

/)/ The CLE8SH74 GU7!E ; -ear %our" Electives 9 Ca8MS



4ick letters 'ased on your connection to the staff +e+'er and your eperience in the rotation Pparticularly if you felt that your strengths #ere highlighted #hen #orking #ith that particularindividual( Select the people that are ecited for you to #ork in that field P so+eone #ho #ill saygreat things a'out you and #ho is also enthusiastic( Try to capitalie on long periods of ti+espent #ith the sa+e Attending P for ea+ple< if you spend si #eeks #ith a 4sychiatry preceptor<they are likely to kno# you #ell enough to #rite a +eaningful letter(


/), The CLE8SH74 GU7!E ; -ear %our" Electives 9 Ca8MS



Ca8MS Applications

The +ost i+portant advice is to start early< especially on the personal letters( 7f you start inSepte+'er @as soon as you get your token to log in and #ork on your application for a couple of

hours each #eek< the process #ill 'e less stressful and you should not 'e too pressed for ti+e(Taking the full t#o +onths #ill help ensure the #ork is +anagea'le(

C U 8 8 7 C U L U M 3 7 A E

A #ell?rounded C3 is i+portant P allo# it to accurately represent the 'readth of interests andactivities in #hich you have participated( Take so+e ti+e to think a'out +a>or strengths that+ight set you apart fro+ others< and ensure these are highlighted in your C3( 7nclude activitiesthat are i+portant to you< 'oth #ithin +edicine and in a non?acade+ic contet( %ocus onactivities that de+onstrate an interest in your specialty as #ell as on etra?curricular interests<research< and volunteering( -ou #ill likely 'e asked a'out +uch of #hat you put on your C3during your intervie#s( Ensure you edit your C3 etensively(

4E8S$&AL S A EME& S

eep in +ind that personal letters +ay reFuire significant ti+e for reflection and editing( -ou canuse the cover letter that you #rote for your referees as a good first draft( Helpful resources includeprogra+?specific infor+ation fro+ #e'sites< your o#n C3< previous applications< CanMEDs co+petencies< sa+ple letters online and those provided 'y UBC< and discussions #ith advisors(Make use of your fa+ily and friends as editorsR have several people read the+ over to provideadvice(

48E4A8A 7$& !U87&G -EA8 ,

eep your C3 up to date< including all your clinical rotations #ith the nu+'er of #eeks( *rite acover letter for your referees eplaining #hy you are particularly suited to your specialty ofinterest(

%inally< keep a list or >ournal focused on +eaningful clinical eperiences as you progress throughthird year( Start thinking a'out clinical vignettes fro+ your o#n eperience that #ill 'e helpful 'oth for your letters and for intervie#s(



http://rcpsc.medical.org/canmeds/CanMEDS2005/index.php

http://rcpsc.medical.org/canmeds/CanMEDS2005/index.php



Ca8MS 7ntervie#s

48E4A87&G %$8 CA8MS 7& E837E*S

Ca8MS intervie#s reFuire preparation and practice( -ou #ill need to Fuickly recall anecdotesand stories( Start 'y going through a selection of the availa'le sa+ple Fuestions and +ake noteson #hat you #ant to re+e+'er to say( Useful resources include the intervie# data'ase on the

CFMS website< the $SA intervie# preparation session< the 4M4 student handout< the C%MSCa8MS 8esidency Guide< and specific infor+ation on progra+ #e'sites(

Start thinking a'out ans#ers to co++on Fuestions< especially #hy you are +ost interested in and#ell suited to the specialty to #hich you applied( Most students #ho attend the 4M4 practiceCa8MS intervie#s sessions find the+ very helpful( *hile it can 'e inti+idating to sit in front ofyour peers and ans#er Fuestions< this provides an ecellent learning opportunity and +uch?needed practice( !onDt 'e afraid to look silly during practice P it is 'etter in practice than at yourintervie#. Also practice #ith fa+ily and friends to ensure you have a chance to practice tellingstories< listen to your #ording< and receive feed'ack on ho# you sound(

Take ti+e for self?reflection P kno# #ho you are and your strengths and #eaknesses( Think overclinical encounters that #ere difficult< challenging< or taught you so+ething specific( Considerdeveloping so+e key stories 'ased on +eaningful clinical eperiences that highlight a variety ofthe+es related to co++only asked Fuestions @e(g( adversity< leadership< personal Fualities( Alsothink a'out ho# to outline

CanME!S co+petencies #ith ea+ples fro+ your training( 8e+e+'er that this process is easier

if you keep track of +eaningful encounters throughout +edical school(

OUES 7$&S $ AS !U87&G 7& E837E*S A&! S$C7AL E3E& S

Al#ays think a'out a fe# Fuestions you could ask if given the opportunity( These +ight covertopics such as training opportunities 'oth locally and internationally< the etent to #hichresidents feel prepared for practice #hen they finish< and #hat residents or staff +ight changea'out the progra+ if they could( eep the discussion pleasant and positive 'ut ask a'out theprogra+Ds strengths and #eaknesses( 7n short< use the opportunity to learn a'out the progra+and to try to figure out #hether it is a good fit for you( Ask a'out #hatever genuinely interests

you(

/): The CLE8SH74 GU7!E ; -ear %our" Electives 9 Ca8MS

http://www.cfms.org/

http://www.cfms.org/



7f you already have all the infor+ation you need regarding the progra+< ask your intervie#ersa'out the sites they are fro+< their practices< and their i+pressions of it( 7t is so+eti+es possi'leto ask a'out the intervie#ersD 'ackgrounds at the 'eginning of the intervie#< #hich can help toguide your ans#ers( !uring social events< ask the residents #hether they are happy @in thea'sence of any faculty( Ask the+ a'out call< group dyna+ics< the city< and #hy they chose theprogra+ vs( other progra+s and other sites( Ask the+ #hat they like 'est a'out the progra+<a'out its 'est and #orst attri'utes< and #hether Attendings are keen to +entor and teach(

8A3ELL7&G %$8 CA8MS

Consider 'ooking intervie#s #ith friends #ho are applying to the sa+e specialty< allo#ing you to 'ook flights and hotels together( Take care of yourself during this ti+eR 'ring so+e runners andshorts in case your hotel has a gy+< and re+e+'er that it is +uch colder in other parts of thecountry< so dress accordingly( Consider a rolling or easy?to?carry gar+ent 'ag< and try to stick tocarry?on luggage to save ti+e and stress at the airport( Try to give yourself lots of ti+e 'et#eenintervie#s< allo#ing for unforeseen #inter travel delays( So+e people try to sFueee intervie#stogether in order to take a vacation at the end< 'ut leaving ti+e to recharge 'et#een intervie#scan help(

H$* $ !8ESS

4ack your suit in a carry?on so that it is al#ays #ith you< and try to travel light( Attire forintervie#s is typically 'usiness for+al P suits are the standard( Ho#ever< you can check theCa8MS #e'site for the progra+ for and specific instructions regarding the intervie#< as so+erural progra+s +ay have other dress guidelines( -ou +ay need to 'ring your luggage #ith you toan intervie#< and there is al#ays a roo+ in #hich you can store it( -ou +ay #ant to take notesduring the orientationpresentation sessions 'ut do not need to 'ring anything into the intervie#(Most invitations #ill tell you the dress code for social events( This is usually so+ething close to

'usiness casual< although so+e events +ay 'e considera'ly +ore casual( -ou +ight consider 'ringing t#o options @one dressier and one +ore casual if you are unsure a'out the venue(





HA&S %$8 HE

8EA!.

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