Clinicians Pocket Reference, 11th Edition

"So You Want to Be a Scut Monkey": An Introduction to Clinical Medicine*: Introduction

The transition from the preclinical years to the clinical years of medical school is an important time. Understanding the new responsibilities and the general ground rules can ease this transition. Here we provide a brief introduction to clinical medical training for the new student on the wards.

*Based on a concept initially developed by Epstein A, Frye T (eds.): So You Want to Be a Toad. College of Medicine, Ohio State University, Columbus, OH.

The Hierarchy

Most services have some or all of the following team members.

The Intern

In some programs, the intern is also known as the first-year resident. This person has the day-to-day responsibilities of patient care. This duty, combined with a total lack of seniority, usually serves to keep the intern in the hospital more than the other members of the team and may limit his or her teaching of medical students. Any question you have concerning details in the evaluation of the patient, for example, whether Mrs. Pavona gets a complete blood count this morning or this evening, is usually referred first to the intern.

The Resident

The resident is a member of the house staff who has completed at least 1 year of postgraduate medical education. The most senior resident is typically in charge of the overall conduct of the service and is the person you might ask a question such as "What might cause Mrs. Pavona's white blood cell count to be 142,000?" You might also ask your resident for an appropriate reference on the subject or perhaps to arrange a brief conference on the topic for everyone on the service. A surgical service typically has a chief resident, a physician in the last year of residency who usually runs the day-to-day activities of the service. On medical services the chief resident is usually an appointee of the chair of medicine and primarily has administrative responsibilities often with limited ward duties.

The Attending Physician

The attending physician is also called simply "The Attending," and on nonsurgical services, "the attending." (Note: Before we get any more letters yes, this is a joke!) This physician has completed postgraduate education and has become a member of the teaching faculty. He or she is usually already board-certified in a specialty but may be newly trained and "board eligible." The attending is morally and legally responsible for the care of all patients whose charts are marked with the attending's name. All major therapeutic decisions made about the care of these patients are ultimately passed by the attending. In addition, this person is responsible for teaching and evaluating house staff and medical students. You might ask this member of the team, "Why are we treating Mrs. Pavona with busulfan?"

The Fellow

The fellow is a physician who has completed his or her postgraduate education and elected to do extra study in one special field, such as nephrology, high-risk obstetrics, or surgical oncology. This person may or may not be an active member of the team and may not be obligated to teach medical students but usually is happy to answer any questions you may ask. You might ask this person to help you read Mrs. Pavona's bone marrow smear.

Physician Extenders

Nurse practitioners and physician assistants are being incorporated into the health care system, including academic medical centers. Their responsibilities vary by service, hospital, and state regulation. These professionals are critical members of the team and excellent resources for both students and patients. You might ask them about Mrs. Pavona's discharge orders.

Teamwork

The medical student, in addition to being a member of the medical team, must interact with members of the professional team of nurses, dietitians, pharmacists, social workers, physician assistants, nurse practitioners, and all others who provide direct care for the patient. Good working relations with this group of professionals can make your work go more smoothly; bad relations with them can make your rotation miserable.

Nurses are generally good-tempered but are overworked in most systems. Like most human beings, they respond favorably to polite treatment. Leaving a mess in a patient's room after a floor procedure, standing by idly while a 98-lb licensed practical nurse struggles to move a 350-lb patient onto the chair scale, and obviously listening to three ringing telephones while room call lights flash are acts guaranteed not to please. Do not let anyone talk you into being an acting nurse's aide or ward secretary, but try to be polite and help when you can.

You will occasionally meet a staff member who is having a bad day, and you will be able to do little about it. Returning hostility is unwarranted at these times, and it is best to avoid confrontations except when necessary for the appropriate care of the patient.

When faced with ordering a diet for your first sick patient, you might be confronted with the limitation in your education in nutrition. Fortunately, dietitians are available, and you should never hesitate to call one.

In matters concerning drug interactions, side effects, individualization of dosages, alterations of drug dosing in disease, and equivalence of different brands of the same drug, it never hurts to call the pharmacist. Most academic medical centers have a PharmD resident who follows inpatients on a given floor or service and who will gladly answer any questions and is an excellent resource for additional reference materials.

Your Health and a Word on "Aggressiveness"

In your months of curing disease both day and night, it becomes easy to ignore your own right to keep yourself healthy. With the implementation of the Accreditation Council for Graduate Medical Education (ACGME) guidelines on resident duty hours on July 1, 2004 (www.acgme.org), the numerous bad examples of medical and surgical interns working on 3 hours of sleep a night and eating most of their meals from vending machines have been reduced dramatically. Despite the hit the hospital is taking on sales of candy bars, do not let anyone talk you into believing that you are not entitled to decent meals and sleep, even if the ACGME 80-hour work week rules do not apply to students (yet!). If you offer yourself as a sacrifice, it will be a rare rotation on which you will not become one. On the other hand, try to extend yourself when the need arises. The house staff will appreciate it, and because the house staff usually has significant input into your grade, it may reflect itself in an outstanding grade on the rotation.

You may have the misfortune someday of reading an evaluation that says you were not "aggressive enough." This notion is enigmatic to everyone. Does it mean that the student refused to attempt to start an intravenous line after eight previous failures? Does it mean that the student was not consistently the first to shout out the answer over the mumbling of fellow students on rounds? Whatever constitutes "aggressiveness" must be a dubious virtue at best.

A more appropriate virtue might be assertiveness in obtaining your education. Ask good questions, read about your patient's illness, review the basics of a procedure before going to the OR, participate actively in your patient's care, take an interest in other patients on the service, and have the house staff show you procedures and review your chartwork. This approach avoids the need for victimizing your patients and comrades, as the definition of aggression suggests.

Rounds

Rounds are meetings of all members of the service for discussing the care of the patient. Rounds occur daily and are of three kinds.

Morning Rounds

Also known as "work rounds," morning rounds take place anywhere from 6:00 to 9:00 AM on most services and are attended by residents, interns, and students. Morning rounds are the time for discussing what happened to the patient during the night, the progress of the patient's evaluation or therapy or both, the laboratory and radiologic tests to be ordered for the patient, and, last but not least, talking with and evaluating the patient. Know about your patient's most recent laboratory reports and progress this is a chance for you to look good.

Ideally, differences of opinion and glaring omissions in patient care are politely discussed and resolved at morning rounds. Writing new orders, filling out consultation forms, and making telephone calls related to the patient's care are best done right after morning rounds.

Attending Rounds

Attending rounds vary greatly depending on the service and on the nature of the attending physician. The same people who gathered for morning rounds are at attending rounds, as is the attending. At this meeting, patients are often seen again (especially on the surgical services); significant new laboratory, radiographic, and physical findings are described (often by the student caring for the patient); and new patients are formally presented to the attending (again, often by the medical student).

The most important priority for the student on attending rounds is to know the patient. Be prepared to concisely tell the attending what has happened to the patient. Also be ready to give a brief presentation on the patient's illness, especially if it is unusual. The attending will probably not be interested in minor details that do not affect therapeutic decisions. In addition, the attending will probably not wish to hear a litany of normal laboratory values, only the pertinent ones, such as "Mrs. Pavona's platelets are still 350,000/mL in spite of her bone marrow disease." You do not have to tell everything you know on rounds, but you must be prepared to do so.

Disputes among house staff and students usually are bad form on attending rounds. For this reason, the unwritten rule is that any differences of opinion not previously discussed should not be raised initially in the presence of the attending.

Check-Out or Evening Rounds

Formal evening rounds on which the patients are seen by the entire team a second time are typically done only on surgical and pediatric services. Other services, such as medicine, often have check-out with the resident on call for the service that evening (sometimes called "card rounds"). Expect to convene for check-out rounds between 3:00 and 7:00 PM on most days.

All new data are presented by the person who collected them (often the student). Orders are again written, laboratory work desired for early the next day is requested, and those on call compile a "scut list" of work to be done that night and a list of patients who need close supervision. To comply with the ACGME directive regarding an 80-hour work week, many services have adopted "night-float" coverage systems. The interns and residents caring for your patients overnight will meet with the team at evening sign-out rounds. These cross-coverage strategies call for clear, concise communication essential during rounds.

Bedside Rounds

Bedside rounds are basically the same as other rounds except that tact is at a premium. The first consideration at the bedside must be for the patient. If no one else on the team says "Good morning" and asks how the patient is feeling, do it yourself; this is not a presumptuous act on your part. Keep this encounter brief and then explain to the patient that you will be talking about him or her for a while. Most patients treated this way feel flattered by the attention and listen with interest.

Certain points of a hallway presentation are omitted in the patient's room. The patient's race and sex are usually apparent to all and do not warrant inclusion in your first sentence.

The patient must never be called by the name of the disease, eg, Mrs. Pavona is not "a 45-year-old CML (chronic myelogenous leukemia)" but "a 45-year-old with CML." The patient's general appearance need not be reiterated. Descriptions of evidence of disease must not be prefaced by words such as outstanding or beautiful. Mrs. Pavona's massive spleen is not beautiful to her, and it should not be to the physician or student either.

At the bedside, keep both feet on the floor. A foot up on a bed or chair conveys impatience and disinterest to the patient and other members of the team. It is poor form to carry beverages or food into the patient's room.

Although you will probably never be asked to examine a patient during bedside rounds, it is still worthwhile to know how to do so considerately. Bedside examinations are often done by the attending at the time of the initial presentation or by one member of a surgical service on postoperative rounds. First, warn the patient that you are about to examine the wound or affected part. Ask the patient to uncover whatever needs to be exposed rather than boldly removing the patient's clothes yourself. If the patient is unable to do so alone, you may do it, but remember to explain what you are doing. Remove only as much clothing as is necessary, and then promptly cover the patient again. In a ward room, remember to pull the curtain.

Bedside rounds in the intensive care unit call for as much consideration as they do in any other room. That still, naked person on the bed may not be as "out of it" as the resident (or anyone else) believes and may be hearing every word you say. Again, exercise discretion in discussing the patient's illness, plan, prognosis, and personal character as it relates to the disease.

Remember that patient information with which you are entrusted as a health care provider is confidential. There is a time and place to discuss this sensitive information, and public areas such as elevators or cafeterias are not the appropriate location for these discussions.

Reading

Time for reading is at a premium on many services, and it is therefore important to use that time effectively. Unless you can remember everything you learned in the first 20 months of medical school, you will probably want to review the basic facts about the disease that brought your patient into the hospital. These facts are most often found in the same core texts that got you through the preclinical years. Unless specifically directed to do so, avoid the temptation to log on to MEDLINE to find all the latest articles on a disease you have not read about for the last 7 months; you do not have the time.

The appropriate time to head for MEDLINE is when a therapeutic dilemma arises and only the most recent literature will adequately advise the team. You may wish to obtain some direction from the attending, the fellow, or the resident before plunging online or into the library on your only Friday night off call this month. Ask the residents and your fellow students which pocket manuals and PDA downloads they found most useful for a given rotation.

The Written History and Physical

Much has been written on how to obtain a useful medical history and perform a thorough physical examination, and there is little to add here. Three things worth emphasizing are your own physical findings, your impression, and your own differential diagnosis.

Trust and record your own physical findings, even if other examiners have written things different from those you found. You just may be right, and if not, you have learned something from it. Avoid the temptation to copy another examiner's findings as your own when you are unable to do the examination yourself. Still, it would be an unusually cruel resident who would make you give Mrs. Pavona her fourth rectal examination of the day, and in this circumstance you may write "rectal per resident." Do not do this routinely just to avoid performing a complete physical examination. Check with the resident first.

Although not always emphasized in physical diagnosis, your clinical impression is probably the most important part of your write-up. Reasoned interpretation of the medical history and physical examination findings is what separates physicians from the computers touted by the tabloids as their successors. Judgment is learned only by boldly stating your case, even if you are wrong more often than not.

The differential diagnosis, that is, your impression, should include only entities that you consider when evaluating your patient. Avoid including every possible cause of your patient's ailments. List only those that you are seriously considering, and include in your plan what you intend to do to exclude each one. Save the exhaustive list for the time your attending asks for all the causes of a symptom, syndrome, or abnormal laboratory value.

The Presentation

The object of the presentation is to briefly and concisely (usually in a few minutes) describe your patient's reason for being in the hospital to all members of the team who do not know the patient and the story. Unlike the write-up, which contains all the data you obtained, the presentation may include only the pertinent positive and negative evidence of a disease and its course in the patient. It is hard to get a feel for what is pertinent until you have seen and done a few presentations yourself.

Practice is important. Try never to read from your write-up, because doing so often produces dull and lengthy presentations. Most attendings will allow you to carry note cards, but this method can also lead to trouble unless content is carefully edited. Presentations are given in the same order as a write-up: identification, chief complaint, history of the present illness, past medical history, family history, psychosocial history, review of systems, physical examination, laboratory and x-ray data, clinical impression, and plan. Only pertinent positives and negatives from the review of systems should be given. These and truly relevant items from other parts of the interview often can be added to the history of the present illness. Finally, the length and content of the presentation vary greatly according to the wishes of the attending and the resident, but you will learn quickly what they do and do not want.

Responsibility

Your responsibilities as a student should be clearly defined on the first day of a rotation by either the attending or the resident. Ideally, this enumeration of your duties should also include a list of what you might expect concerning teaching, floor skills, presentations, and all the other things you are paying many thousands of dollars a year to learn.

On some services, you may feel like a glorified unit secretary (clinical rotations are called "clerkships" for good reason!), and you will not be far from wrong. This is not what you are going into hock for. The scut work should be divided among the house staff and students.

You will frequently be expected to call for a certain piece of laboratory data or to go review an x-ray with the radiologist. You may then mutter under your breath, "Why waste my time? The report will be on the chart in a day or two!" You will feel less annoyed in this situation if you consider that every piece of data ordered is vital to the care of your patient.

Outpatient clinic experiences are incorporated into many rotations. The same basic rules and skill set necessary for in-patient care can be easily transferred to the outpatient setting. The student's responsibility, again, can be summarized in three words: know your patient. The entire service relies to a great extent on a well-informed presentation by the student. The better informed you are, the more time is left for education, and the better your evaluation will be. A major part of becoming a physician is learning responsibility.

Orders

Orders are the physician's instructions to nurses and other members of the professional staff concerning the care of the patient. These instructions may include the frequency of assessment of vital signs, administration of medications, respiratory care, laboratory and x-ray studies, and nearly anything else that you can imagine.

There are many formats for writing concise admission, transfer, and postoperative orders. Some rotations may have a precisely fixed set of routine orders, but others leave you and the intern to your own devices. It is important in each case to avoid omitting instructions critical to the care of the patient. Although you will be confronted with a variety of lists and mnemonics, ultimately it is helpful to devise your own system and commit it to memory. Why memorize? Because when you are an intern and it is 3:30 AM, you may overlook something if you try to think it out. One system for writing admission or transfer orders uses the mnemonic "A.A.D.C. VAAN DISSL," which is discussed in Chapter 2.

The word stat is the abbreviation for the Latin word statim, which means "immediately." When added to any order, it puts the requested study in front of all the routine work waiting to be done. Ideally, a stat order is reserved for the truly urgent situation, but in practice it is often inappropriately used. Most of the blame for this situation rests with physicians who either fail to plan ahead or order stat lab results when routine studies would do.

Student orders usually require a cosignature from a physician, although at some institutions students are allowed to order routine laboratory studies. Do not ask a nurse or pharmacist to act on an unsigned student order; it is illegal for them to do so.

The intern is responsible for most orders. The amount of interest shown by the resident and the attending varies greatly, but ideally you will review with the intern the orders for routinely admitted patients. Have the intern show you how to write orders for a few patients, then take the initiative and write the orders yourself and review them with the intern. Unfortunately, this important part of learning basic patient care is becoming increasingly difficult as many medical centers make the transition from paper charts to electronic medical records. Even if your hospital uses computerized orders, take the opportunity to watch the intern or resident entering the orders when you admit patients.

The Day

The events of the day and the effective use of time are two of the most distressing enigmas encountered in making the transition from preclinical to clinical education. For example, there are no typical days on surgical services because the operating room schedule prohibits making rounds at a regularly scheduled time every day. The following suggestions will help on any service.

1. Schedule special studies early in the day. The free time after work rounds is usually ideal for this task. Also, call consultants early in the morning. Often they can see your patient on the same day or at least early the next day.

2. Take care of all your business in the radiology department in one trip unless a given problem requires viewing a film promptly. Do not make as many separate trips as you have patients.

3. Make a point of knowing when certain services become unavailable, for example, for electrocardiograms, contrast-study scheduling, and blood drawing. Be sure to get these procedures done while it is still possible to do so.

4. Make a daily work or "scut"* list, and write down laboratory results as soon as you obtain them. Few people can keep all the daily data in their heads without making errors.

5. Arrange your travels around the hospital efficiently. If you have patients to see on four different floors, try to take care of all their needs, such as drawing blood, removing sutures, writing progress notes, and calling for consultations, in one trip.

6. Strive to work thoroughly but quickly. If you do not try to get work done early, you never will (this is not to say that you will succeed even if you do try). There is no sin in leaving at 5:00 PM or earlier if your obligations are completed and the supervising resident has dismissed you.

*Although the origin of how the word scut (real definition: the tail of a hare) entered the medical jargon is obscure, we like to think it represents an acronym for "some common unfinished task" or "some clinically useful training."

A Parting Shot

The clinical years are when all the years of premed study in college and the first 2 years of medical school suddenly come together. Trying to tell you adequately about being a clinical clerk is similar to trying to make someone into a swimmer on dry land. The terms for describing new clinical clerks ("scut monkey," "scut boy," "scut dog," "torpedoes") vary from medical center to medical center. These expressions describing the new clinical clerk acknowledge that the transition, a rite of passage, into the next phase of physician training has occurred.

We hope that this "So You Want to Be a Scut Monkey" introduction and the information contained in this book will give you a good start as you enter the "hands-on" phase of becoming a successful and respected physician.