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The Art of Clerking In

“Dr GP is sending us a patient to be admitted for pain control. Sefkhet, can you clerk her in?” Yes. Yes, I can. I’ve, uh, I’ve never actually done it before, though. “Oh, it’s easy. Just do what it says on the form.” And so it came to pass that I found myself on the medical admissions unit, looking like someone who ought to have known what she was doing and gripping the clerk-in form like a security blanket. And thinking that it couldn’t possibly be as easy as my F2 had made it sound.

First, to explain something of what I’m talking about. The “clerking-in” is what happens when someone is being admitted to hospital. It is basically a full medical everything. From the patient’s point of view, this means being asked lots of questions that either don’t seem terribly relevant or were already asked by their GP and/or A&E and then being used as a pincushion

The clerk-in form is a magnificent invention that: a) provides a consistent format for recording screeds of information, and b) acts as a prompt for all the things that you would otherwise forget to do. However, it is not quite so simple as “just do what it says on the form”. I had an exceedingly cooperative patient who was being admitted for pain control on her arthritic shoulder. I made her sit through a full neurological examination but didn’t dare touch the shoulder.

1. read the old notes
Or the GP letter. Or the SBAR from A&E. Or whatever. At worst, it means that there’s verification of what they’ve told you. At best, it means that you don’t struggle through getting a medical history only to find later that the patient who looked completely sane was actually completely demented and making things up as she went along. Oh, but I did.

2. the end-of-the-bed test
There are some patients who just look sick. Like, really sick. Sometimes, it’s all right to stop your clerk-in and go to find a doctor.

3. sit down
It’s not a five minute job. It isn’t made more comfortable either for you or for the patient when you spend the entire half hour looming over them.

4. the form isn’t a substitute for knowing what to do
I’ve used clerk-in forms that have prompted everything — where the section for GI examination includes a blank schematic of the abdomen and space to comment on organ size and bowel sounds. And I’ve used clerk-in forms that have “GI Exam” and then some empty white space. Besides, being reminded to comment on the spleen only helps if you already know how to palpate for it. (I was worried about causing pain, but my bigger reason for not examining that patient’s shoulder was that I didn’t know how.)

5. presenting complaint
The presenting complaint is the thing that is wrong with the patient, in their words. Generally, appendicitis is not a presenting complaint — stomach pain is a presenting complaint. Mind, I once had a patient whose actual presenting complaint was atrial myxoma, but I suppose there are exceptions to every rule.

6. the concept of background history
The taught format for taking a medical history is very very structured. It works. In real life, things are a little more flexible. You’re allowed to record relevant details from other parts of the history under the presenting complaint. If a patient presents with crushing chest pain, their history of unstable angina and previous CABG is part of the presenting complaint. Yes, you have to write it down again under past medical history, but that’s okay.

7. the art of medicines reconciliation
If the patient offers a plastic bag full of their medications or a copy of their last prescriptions, take them. It’s a much easier and much more reliable way of getting an accurate drug history than expecting patients to remember the names and doses and times of all their drugs. Of course, not everyone is on seventeen different drugs. But the ones who offer usually are.

8. when not to do a neuro exam
As a general rule, everyone gets their heart and lungs listened to and a hand laid on their abdomen. As a general rule, not everyone needs to have a neuro exam. If they aren’t presenting with neurological symptoms, “grossly intact” or “alert and oriented / moving all four limbs” is usually enough.

9. think about getting the bloods first
Yes, they are at the end of the form. It doesn’t mean that they have to be done at the end. This is especially true when you’re at a hospital in the arse end of nowhere and there aren’t out-of-hours lab facilities and your patient turns up at 4pm on a Friday. Similarly, sending off the x-ray request first means that the patient might actually get their x-ray before all the radiologists go home. Again, especially if you’re at a hospital in the arse end of nowhere.

10. find someone to present it to
It is not quite so simple as “just do what it says on the form”, but that’s the only way you ever really learn how to do it. You do what it says on the form. And then you present it to someone so that you can learn how to do it better next time.

 
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Posted by on January 31, 2011 in Blog, Medicine

 

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And Sorry That I Could Not Travel Both

A thick blanket of freezing fog has descended across the city. It’s nothing like so cold as in December (I have not yet forgotten walking to an MDT meeting when it was minus twelve degrees outside), but there’s a distinct bite in the air, enough to make me shiver and walk that little bit faster if I need to pass through the main lobby of the hospital. It feels all the colder for the few days of almost autumnal weather we had last week.

It’s the second week of my second SSC, which was supposed to be on haematological malignancies and has ended up being on general haematology. I’m rethinking my career choices.

I am not alarmed by this. I always do it. I work in a field for a little bit and enjoy it so much that I cannot help but think, “I want to do this for a job!” I spent two days in October thinking that I would really rather enjoy being a cardiologist, even with the seven hour ward rounds.

But…

I don’t know, I think there’s something different about this. I think there are a lot of things to like about haematology, a lot of things that seem to add up to the sort of doctor that I’ve been working out that I want to be. I think the thing is that I want to do oncology, and this isn’t not oncology. It’s more specific and yet more generalist than that, but it still is that. In America, haematology and medical oncology are one specialty and I suppose in my ideal world we would do something like that. I understand why we don’t, though; it seems like a dauntingly enormous specialty. I think that this is one of those paragraphs that maybe made more sense inside my head.

Truthfully, it’s the fact of it involving lab work that makes me think twice. The lab and the MRCPath, oh God.

And a little bit because I should perhaps not make these sorts of decisions based on what nice people all the haematologists are or how happy I am to be back in medicine after five weeks of mostly surgery.

I have time to make my mind up. Years.

I do, though. Now, at this moment. I want to do this.

 
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Posted by on January 20, 2011 in Blog, Medicine

 

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Joy, Blessings, and Happiness

The very merriest of Christmases to you and to all whom you love.

 
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Posted by on December 25, 2010 in Blog

 

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So Near, So Far

I am becoming convinced that the sole purpose of the last week of term is to slowly suck the life out of all medical students. This is Academic Week. It is five days of shivering in lecture theatres with inadequate central heating while being talked at about things that we already know.

Yesterday, we sat through an afternoon that would perhaps have been useful if we had had it in Year 1, Week 1. Not Year 4, Week 16. The unfortunate soul who had been asked to deliver a lecture on basic immunology opened with a statement that nothing he planned to say would have any relevance at all to our exams. In a reference to Th1 and Th2 cells, he said doubtfully that some of us might have heard of those. I’d be surprised if more than half of the year was awake — especially after he said out loud that we wouldn’t miss much if we went to sleep. I think most of us who stayed awake did so only because it was too bloody cold to go to sleep.

Today, three separate people referred to the Disability Discrimination Act as though it still exists. I am probably not the only one who thinks that a conversation about disability law would be more valuable if it was had in the context of the actual legislation.

I live in hope that the rest of the week will be less painful, but I am not holding my breath.

 
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Posted by on December 14, 2010 in Blog, Medicine

 

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Looming Deadlines

I’d had wonderful plans for this SSM. I’ve not got a proper obs and gynae block until last thing in fifth year, and, although my SSM is supposed to be in gynae oncology, the timetable is really not too terribly busy and I had all these grand ideas that I’d try to at least see some of the routine gynae and go to an antenatal clinic and maybe try to get into a delivery. I thought that it might make me less likely to panic come next January. Of course, I’ve done none of those things and now find myself with a week to go and hand-in dates approaching. My flatmate and I had made all sorts of promises to ourselves about getting work done on Monday night, but between the snow and the twinkly twinkly lights that turned into making hot chocolate and watching The Holiday. It may not have been the most productive way to spend an evening, but it made us almost stupidly happy.

All good things must pause, though, and this weekend is time to knuckle down. I’m a quarter of the way into my first case report (of three), have nine journal articles on vulval carcinoma open on my laptop, and a scribble-covered notepad on my desk.

It’s not like I’ve never written 6000+ words in six days before…

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Now playing: Glenn Close – With One Look from Sunset Boulevard

 
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Posted by on December 4, 2010 in Blog, Medicine

 

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See One, Do One… Teach One?

In one of my earlier rotations this year, I was landed with a work experience student for a bit.

Really, it’s more accurate to say that she was landed with me.

I am fairly obviously not even a little bit qualified for such a thing. I can’t tell anyone what it’s like to be a doctor, not really, and sixteen-year-olds do not go on work experience to find out what it’s like to be a medical student. If they’re anything like most of us when we were their age, sixteen-year-olds go on work experience harbouring the fond delusion that they might get to assist on brain surgery. So far as I can gather, her consultant thought that she’d learn more about what she might be getting herself into if she shadowed a junior doctor, and the junior doctor followed that thought to its logical conclusion and thought that she’d learn more about what she might be getting herself into if she shadowed, well, me. It might be true. It might even have given her something a little bit different to talk about in interviews and I hope it did.

On a purely selfish note, I do admit that it was nice to not be the most junior person on the ward round for once.

Still, watching me look lost and useless isn’t what I’d call the most inspiring sight. I was in my first five minutes on a new ward when she joined me — ‘lost and useless’ isn’t an exaggeration, the poor girl spent a decent chunk of time that afternoon watching me spin slowly in circles in the middle of the treatment room as I bemoaned an apparent lack of syringes. And even if I eventually stopped looking lost and useless, it’s not as though I was empowered to do much with her. I showed her how to take bloods and do venflons, and I showed her how not to do blood gases and demonstrated the art of giving yourself a needlestick injury with a heparinised needle. In spite of my best efforts to find her someone interesting to be with for a few hours, she ended up at one point in a tutorial on diabetic emergencies that included things that went over the top of my head.

It’s been a long time since I did my work experience, and an even longer time since I was sixteen. I don’t know if I had much of an idea what I was trying to achieve with it, back then The clearest memory I have is of the SHO who tried valiantly to teach me some radiology, asking what was abnormal about the CXR of a patient who was coming into outpatient clinic. “Well, I’m sure that this big thing in the middle of the lung probably isn’t supposed to be there, so I think he might have cancer,” I said, with the absolute certainty possessed only by someone who knows nothing but has a shiny new batch of good GCSEs and is therefore convinced of her brilliance. Of course, my brilliance was undermined somewhat by the fact that I was pointing at the left heart border. I tell this story to demonstrate that no matter how ridiculous you think you might sound, there is always someone who has said something stupider than whatever it is that you’re about to say.

In any case, it got me thinking: what do you guys want to get out of your work experience? I’m asking mostly out of curiosity; after all, I don’t expect personally to be faced with that question again for at least the next few years. I would really like to know, though. I feel like if I don’t know what I wanted from my work experience (and if I don’t know the answer to that now, I never will), then I’m hardly going to be in a position to make assumptions about what other people want from theirs.
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Now playing: Bruch – Violin Concerto No. 1 in G minor, Op. 26 – 2nd movement

 
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Posted by on November 25, 2010 in Blog, Medicine

 

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No Place Like Home

Since my last post, I’ve returned from my rural placement and I’m back in civilisation.

I’m thinking about applying there for FY1, actually. It’s a pretty part of the world, even though I am not  remotely what you’d call a country person, and a lovely hospital with good teaching and some of the nicest people I’ve ever worked with. I loved my time there.  It’s just that  I love having my bed back more. I’ve only been home since Friday, and I’m still revelling in the luxury of having my bed, my bookshelves, my cathedral, and my spice rack be less than a two hour drive away.

In my previous block, I was commuting halfway across Scotland on a daily basis.

It is by no means an exaggeration to say that the most exciting part of my current SSM is that my main hospital is a ten minute journey from my house.
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Now playing: Brahms – Symphony No. 2 In D Major

 
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Posted by on November 11, 2010 in Blog, Medicine

 

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