Dec 12, 2010

Life as Clerk 1

Fifth year medical students are called 'Clerk 1' in the hospital. True to the name, we spend most of our working hours doing clerical work - writing all kinds of notes, filling up boxes in our clerkship passport, writing case reports, planning case discussions. Those with limited medical vocabulary or poor mastery of English grammar will suffer from miscommunication in note writing. We also learn to filter information - fever with a history of animal contact: goes in chart; diarrhea, and a fight in class the day before: ignore - much as we know some trivial piece of information may be a key to a different diagnosis, current medical education dictates every patient is at best given one diagnosis and all other unrelated information goes elsewhere.
Life typically begins at 8 with a one-hour morning meeting hosted by the chief resident. A case will be presented with information and knowledge shared among colleagues. Senior physicians will provide guidance to unsolved problems while children like us write everything down like reporters interviewing the president. At 9 attending physicians (or visiting staff, VS in Taiwan) start their outpatient rounds while residents (Rs) begin their long hard day taking care of ward patients. An R gets up to 15 ward patients; interns (seventh year med. student) up to 5, while clerks get a maximum of 2 beds only. Before our VS come visit we should complete surveying all patients under our care - vital signs, conditions the day before, latest lab results, patient's complaints and expectations.
In our smallish hospital, a VS has 1 R, 1 intern, and at most 2 clerks to abuse. That adds up to a max of 25 beds per day. A typical ward round goes like this:

VS: Good morning, this is eerm...
Intern: [patient's name], admitted for fever up to 39 Celcius yesterday.
VS: Feeling better?
Intern: No fever after admission. Urine analysis shows some bacteria and white blood cells, so [antibiotic name] will be used empirically.
VS: Ok, how about other systems? You surveyed? [to patient] any cough? vomiting? diarrhea? dyspnea? abdominal pain?
Patient: Wh...what? Can you...repeat?
VS: Guess not. Any arrangement for a renal sonograph?
Intern: Yes, probably later.
VS: Good, tell me the results as soon as it's out. [to clerks] Why should we do renal sonography?
Clerk: eerm...
VS: Go home and study, tell me about it tomorrow! [to patient] Any questions?
Patient: When can I go home?
VS: As soon as we confirmed your kidney and bladder is ok and you don't have fever for two consecutive days. You will still need to blah-blah.....

We doctors generally have very short attention span. Attendings order workups, drugs, and tests along the way, dictating them like reciting out of the Bible. Rs write them down in illegible writings on the blue patient charts. Clerks and interns follow closely behind listening to heart and lung sounds, performing simple physical examinations on the way.
Then it's time for some mini-lectures, the least mentally taxing part of our day. In the hospital it's not rude to have your mobile phone on full volume, even during lectures. So we're constantly interrupted by a library of ringtones and endless pestering on the phone.
Lunch time is usually 2 hours from 12:00 - 14:00, but being the lowest-ranked, it's the only time we have full access to the chart computers without being interrupted. I usually take a quick lunch, nap (add some reading Time magazine there), and do all my clerical work before station bounce back into activity at 14:00.
Depending on schedule we might have more lessons in the afternoon, a new patient, or idle time until our 17:30 meeting. It's basically a repetition of morning meeting except this time we discuss patient conditions and new patients we approached during this 8 hours. The chief R will do some teaching and reminders. Then we're off. Except if...
You're on night duty today. One would have to stay till 22:00 on a night duty, usually there just being an observer. For me I will present myself to the OPD or ER for the night and see what's happening there. Patience will reward some interesting cases like a child with hyperventilation, or one who swallowed a screw. However, usually it's a series of asthma (very typical during winter).
Then the cycle starts again at 8 tomorrow morning. Everything else goes into the weekends - laundry, movies, buying groceries etc.
So the next time your doctor mistreats you, think twice before lodging a complain - we might just had had a long day. Give us a second chance to prove ourselves!