ADVICE FOR THE MEDICINE CLERKSHIP

The medical team on rounds:

One or two medical students (champs)
Two interns (glorified secretaries)
A second year resident - following patients from both lists
A third year resident - following patients from both lists
An attending

Daily schedule for medicine (roughly):

6am - Alarm goes off. Lie in bed awake thinking of your friends working at Google/in
Finance/anywhere else, and ask yourself, “Why?”.

~7am - Arrive on your unit to pre-round on your patients, depending on where you are in the
clerkship you are and how efficient you are you will need anywhere from 10-30 minutes to
preround on each of your patients.

8am - Rounds with your entire medical team and attending.

First, interns on the night shift will present new patients from the emergency department or other
units that have been admitted to your medical service overnight. Pay attention and take notes
for each patient - you’ll either be assigned “interesting” patients by your attending or will need to
take the initiative to ask the intern/resident to follow the patients you are interested in following
as they are admitted.

Teams have two lists of ~8 patients per intern. Typically the attending will have the interns “run
their lists” (abbrev’d to RTL if you’re cool) after hearing all of the admissions that occurred
overnight or after afternoon rounds from the previous day. Some attendings were proactive and
asked medical students to present their patients first, others just had us present our patients as
they came up while running the list. Bedside rounding seems to be largely a thing of the past,
we typically rounded in our work rooms around computers/Allscripts access, but be prepared to
bedside round if your team will be working with a new attending - a few still enjoy bedside
rounding where you will present a patient outside of their room before entering with the
attending to see them.

Beware: On Wednesdays, Grand Rounds is at 8am so most teams will round at 7am instead of
8 (some cool attendings will just decide to round at 9am, but that is less common). That means
you’ll need to come to the hospital earlier to preround and be ready to present.

~10am-1pm (?? depending on how long your attending rounds) - After rounds each day you will
round with the entire team including attending to visit new patients. Most attendings will see
older patients on their own time without the entire team.
 Some teams during this time may also have interdisciplinary/social work rounds, where
the medical team runs the list with other members of the care team (social work, PT,
pharmacy, nursing). Depending on your attending, you might present your patient here
as well (or you can volunteer if nobody explicitly asks you). The presentation is a little
different, follow your intern’s lead: you can highlight pertinent medical problems but the
focus is really on the estimated date of departure (EDD), any circumstances that the
 nurses should be aware of (e.g. procedures happening that day), and any PT
referrals/social work needs on discharge.

~2-3pm (depending on attending/team preference): Afternoon rounds

Afternoon rounds are typically more focused on teaching rather than patient care. Some
attendings may be as thorough running the list as they were in the morning rounds, others will
simply want to quickly run the list to hear any significant issues/updates.
Interns/residents/attendings will generally let you know the format of afternoon rounds ahead of
time.

Medical students are usually expected to lead the teaching in the afternoon, depending on your
attending’s preference. Sometimes topics or papers were assigned, other times interesting
discussions during rounds were assigned to be researched and presented in afternoon rounds.
Uptodate is a great resource for almost any presentation/topic. Find something interesting in
more recent literature by following the references in any uptodate article or searching Pubmed -
medicine people LOVE evidence-based medicine. Expect to be interrupted repeatedly for
discussion and input from residents/attendings about their understanding/practices.

~4-5pm: Afternoon rounds ends. Residents will generally let you know when you should leave.
One day a week you are supposed to stay late to help with an admission (see more info below).
Before you leave be sure to finish your notes, help your interns with anything that they need
help with, and check in with your patients. The residents and interns were pretty good about
protecting us from doing dirty work (faxing, phone calls, making follow-up appointments, etc.),
but it’s worthwhile to do some of it to understand the ins and outs of how things actually get
done in the hospital so volunteer to help!

When people tell you to leave, and you’ve finished everything you should have done for the day
you should leave. The shelf exam for medicine is gnarly, so you should get out as soon as you
can every day to do what you need to do.

Weekends: Yes, you do have to be there on one weekend day, but they are definitely chiller
(scrubs!). You start at the usual time, but will (hopefully) leave anywhere from noon to ~2pm
unless there is something special worth staying around for. Some attendings are really into the
idea that the two med students should be there on different days, while others couldn’t care
less. It’s best to ask beforehand to see what their preference is.

Using Allscripts:

Allscripts main page:

Click the button next to the red arrow to adjust which columns appear, and change their order to
your liking. You can also just drag and drop the columns to reorder them.

Find your team’s patients using the dropdown box on the top left (see pic below)

If you want, you can merge two lists by creating a new list and adding each of your team’s
lists to the new list.
Flag New - Double click this box (red arrow below), or highlight patients and click the “flag on”
button (red box below) to receive notifications on the allscripts homepage for new orders,
results, documents, etc.

New Orders - After Flag New has been applied for a patient, this box will be with a green flag
when a new order is placed. This is particularly helpful when your intern/residents aren’t great
about filling you in on things that they are doing for patients. You can keep track of orders they
are placing and stay on track.

New Results - As with the New Orders box, this box will populate with a red/yellow flag when
new lab/imaging/etc. results enter the system for your patient. Because of the default layout of
the results tab (listing by date ordered, not date of result), checking this flag is crucial to not
accidentally missing things.

New imaging:
Find all imaging for a patient in PACS (red box).

View new imaging by clicking the button under a new imaging result.
This button shows you the formal impression from radiology (i.e. what you really need
to know)

Other Allscripts tabs:

Positive cultures: check out the Abx sensitivity tab (red box below)

Also on the infonet there is information about NYP Cornell specific bugs/sensitivities (PIC)

Patient info: useful for patient address, patient health insurance plan or patient pharmacy (imp
for discharge)

Prerounding on patients:

Before seeing patients:

Print patient list each morning - editing what appears on the list

-Click on a patient from your list and navigate to the Handoff/Snapshot tab

- Click the “Print Report” hyperlink on the top left

Click “Select All” and then “Create Handoff Report” on the left

On the top right of this page, you should check the box for “Include Cover Sheet”, and press
“Format Report” to adjust what information is included for each patient.
Under “Format Report” it’s useful to put lines between each patient on the Cover Sheet. To do
that adjust this line:

Check the flowsheet tab for vitals each morning (some like the Data vis tab check it out)
Scribble the patients vitals down for later, if relevant you can also find Ins and Outs
(including dialysis I/Os), weight, and bowel movements on this page. Double check with the
patient’s nurse if anything seems odd or confusing.

Check new results (display style report by order vs trend [usually the best to use] vs trend and
graph)
Check new orders
Check documents to see if any new notes have been written by consultants (fyi just ask
nurses/intern/resident about any abbreviations you don’t know after doing your due-diligence of
searching “XYZ medical” into google, unnecessary to waste time figuring it out especially with
the highly specialized consultant notes they can be obnoxious)
Check dose history for relevant medications to see what was given overnight
(If anything looks weird with the medications, the Quality Checklist tab can tell you if a dose was
missed and will have a reason recorded)
Check handoff/snapshot for any overnight notes or changes in summary (It’s not strictly
necessary, but if you want to be really on top of things then you can talk to the nightfloat
resident in the medicine conference room on the 5th floor from like 6:30-7am to actually hear
from them about what happened overnight)

Seeing patients:
Ask your relevant questions - never be afraid to revisit a patient after you see them in the
morning if you forgot to ask about something

Always ask about nausea, vomiting, diarrhea, urination, any other complaints, and if they are
walking around (on their own? With assistance?)

Physical exam:

Essential to perform heart, lungs, abdominal exam, and extremities each morning on all of the
patients you continue to follow. Also perform any other relevant examinations.

Take your time and read/teach yourself the physical exam on your own time. If you have any
questions, think you hear anything weird with your stethoscope, or just want clarification ask
your intern or resident to visit the patient with you between morning and afternoon rounds.

Talk to the nurses if you ever have any questions about what is going on with the patient (or
even if don’t, you’ll still probably learn something you didn’t realize). They can potentially make
your life way better. You can find out who the current nurse for your patient is on Allscripts in the
Handoff tab or on the chat at nurses station. If you can’t find them (or have no idea who they
are), you can either ask whoever is around, call their phone number, or poke your head into the
rooms of the other patients they are taking care of (listed at the nurses station) to see if they’re
around.

Useful things as a medical student:

Check IV/access sites every morning for signs of infection/inflammation - you would look pretty
cool if you caught this first
Check foley catheter and log urine output, if relevant

Preparing for morning presentation:

No one will (should?) fault medical students for taking longer to present patients, and
overstating unnecessary information. Over time you’ll get better at recognizing what is most
relevant to mention during rounds. Often times the attending will hurry you along or ask you to
skip certain parts. Be confident and present the way that you have been taught and adjust your
presentations as needed each day and for each attending/team.

Interval: Describe any acute events that occurred since the last time this patient was discussed
on rounds
Subjective: Speak with patient in the morning and see what is going on - subjectively are they
feeling better, less short of breath, improved abdominal pain, etc.
Objective:
State the patient’s vital signs (some attendings want specific numbers, other just want “stable” if
everything looks good. You’ll get a feel after a day or so)
State new lab results (try to stick to relevant labs, but again not easy as we are still learning so
don’t be afraid to just say everything - learn what the attending likes)
Mention any new medications or those given overnight (meds for sleep, anti-HTN before or after
BP measurement)
Assessment and Plan:
The first attending that I had was very particular about listing each and every problem that a
patient was experiencing and addressing them one by one in descending priority. It took more
time, but was certainly more thorough and made it a lot easier to organize the assessment and
plan. I would suggest this method until you feel comfortable doing otherwise, or if your attending
prefers some other organization.

Example:

1. MRSA pneumonia
- Continue Vanc/Zosyn 1g q24 (day x of y)
- Mention WBC count trend
- Monitor WBC count, fever, etc.

2. Diarrhea/Abdominal pain
- C. diff testing today/pending
- Flagyl dose pending C. diff

3. HTN/CHF
- Continue amlodipine, statin, beta blocker, etc.
Writing out your presentation in the SOAP format on one of your lists in the morning for each
patient really helps to make your presentations go much more smoothly as all of the information
you need is available.
**Make an effort each morning to come up with your own assessment and plan for each of your
patients (even if you’re unsure)! And present this information confidently - it will not only help
you learn, but also attendings and residents love to see you thinking through problems/showing
your own reasoning. Ask your intern/resident to run through it with you before rounds.
The A&P can also be an awesome way to show you’ve read up on your patients (even with little
one-liners like “Mr. X has productive cough, leukocytosis and CXR findings concerning for
aspiration pneumonia, even though he’s afebrile I read that as many as 50% of elderly patients
with pneumonia are afebrile, so we should still continue empiric antibiotics pending sputum
culture results”). Or if you can name-drop a clinical trial that’s relevant to your patient and give a
one-line summary about the results and why they affect your care plan for the patient “In the
AFFIRM trial they found no mortality benefit with rhythm vs. rate control, but found increased
number of adverse side effects in those who took rhythm control medications, so we should
prescribe Ms. Y metoprolol instead of amiodarone for her a-fib”.

Writing Notes:
Click the “Enter Document button in the top left corner

Select Medical/PA Student Free Text Note and Open.

Press F6 (the most clutch key on Allscripts) to bring up the following page:

Click 9 (Note templates…), and select “1. My Templates”. Click “Modify Templates” to import
templates that will pull information about your patient for you automatically each time that you
write a note.

Click “Template” in the top left corner and select “Search Other Providers’ Templates”. Brandon
Maddy has great Admission and SOAP templates. Select one and import, adjust it as you like
(i.e. add your name and pager number to the end of this template so that it imports every time).
Any text that says [<<UPPERCASE INFORMATION>>] will automatically import the respective
information. For example, [<<WEIGHT>>] will automatically import the patient’s most recent
weight when this template is opened.

Save this template when you are done.

Now every time that you open a note to write for your patient press F6, 9 (Note templates), and
select the template that you want to use for your note. It will take a minute to assemble all of the
data that you have designated it to import.

Orders:
Pending vs. active tab
Order button up top (T+1)
Check through orders each day
Magnesium/K - diuretics
Phosphorus - calcium

If you place an order, let whichever resident you’ve sent it to for approval know that you’ve put it
in. Because of the way the system is set up, they will literally never see it to approve it unless
they know to look out for it.

Fun fact: You need a resident’s approval to place an order, but not to discontinue one (you
definitely couldn’t accidentally kill someone by stopping a medication, right?...).

Paging:

Take notes during rounds of who needs to be paged for each of your patients and take the
initiative to send pages after rounds (let the resident/intern know so you both don’t end up
paging the same consultant).

Page from the infonet homepage by clicking “Paging/On-Call” and selecting “Paging/On-Call” :

Search for someone with Last Name, First Name or ID (pager #). Click the green pager button
on the left to send a new page. Fill in the “*NAME::” field with your page (see formatting below).

The format for pages is:

Re: Patient last name, first name (medical record number): question/page statement. Thanks!
Your name (pager number and call back number for your team’s workstation)

For example:
Re: Trump, Donald (666-6666): following up regarding psych consult, okay to discharge patient
as soon as possible? Thanks! R Williams p10963 (746-xxxx)

Keep it to less than 240 characters - no one appreciates multiple incoming pages about the
same patient. If you need to cut the length down for the character limit, they are fine with using
abbreviations (pre-teen texting), cutting out the patient’s first name, dropping spaces between
sentences, etc.

Admissions:
Probably the most useful thing to do on the medicine rotation is to admit a patient and follow
their care throughout their stay in the hospital.

When a new patient is admitted to your service, check the following to get a basic idea about
their presentation:

Vitals (are they stable or should they actually have been admitted to the ICU)
Flowsheets
Initial ED note
Results
Orders
Outpatient medication review
Epic history as needed (button top right of screen)

Use the allscripts admission template described above to put all of the information together after
you have seen and interviewed the patient. Discuss with your intern or resident the plan for the
patient (try to come up with it on your own beforehand). Use the admission note template as
your guide for presenting the patient, the format for presenting new patients is in the same order
as this template.

If they have any EKG abnormality, it helps to print out both the current EKG and their most
recent prior EKG as a comparison. Some attendings won’t care, but others are huge sticklers for
this.

Miscellaneous:
Physical Diagnosis quiz - Our group put together this huge guide extracting details relevant for
each of the teaching points Dr. Esquivel sent us, you can find it here.

Fair warning, our group’s average was in the ~50% ballpark, just accept defeat at the hands of
Dr. Esquivel and move on it’s a small fraction of your grade. That said, it’s still worth studying for
- you’ll learn a lot.

EKG quiz - Life in the Fast Lane is a great resource for learning EKGs. Others swore by
Dubin’s Rapid Interpretation of EKGs - it’s three hundred pages but you can read through it
pretty quickly.

For practice EKGs check out Wave Maven.

Similar destruction occurred on this quiz, but I feel a heck of a lot more comfortable reading
EKGs now.

Useful things for the clerkship:

Bring your laptop if you’re having trouble finding a workstation - you can access allscripts by
going to ita5.nyp.org/ITA/Remote/auth/login.aspx
Whitecoat clipboard
Pocket Medicine - reading through this on rounds looks a lot better than being on your phone
googling things
Tarascon Pocket Pharmacopoeia - congrats on finishing up learning all of the generic names of
medications, no one uses them.

Studying:
UWorld
Online Med Ed - Free videos on everything

Good luck, you’ll crush it. Take the initiative to do things, you’ll learn more. Don’t be afraid to
make mistakes, better now than later when you have more meaningful responsibilities.