Shifting from the classroom to the clinic

Preface
One of the big steps in medical school is seeing your first real patient. After years of roleplay, exams, lectures and labs, we are confronted with a real person who actually has a real problem and we get the privilege of having some role in their healthcare journey.

The shift to real clinical experiences is often viewed with a heart-pounding mix of excitement and trepidation by medical students. I personally was terrified of doing something wrong, getting something wrong, saying something wrong. I learned very quickly that being wrong happens a lot. But almost every mistake is an opportunity to learn, and I truly believe that we should be making these mistakes now as medical students, while we are supervised and in a safe environment.

My very first day I was asked if I would like to put in an intravenous line, having never seen it done before. With some gentle guidance from a very kind house officer, I managed to get it in quickly and smoothly. The doctor then gave me a Tegaderm (a plaster to put over the site to prevent infection and stop the line slipping out) and promptly left. Having never put one on before, I put it on upside down, and walked away feeling very full of myself. Later, when I realized my mistake, I was mortified. Since then, I’ve failed more IV lines than I can count, but my Tegaderms are always meticulously placed.

Success feels good, but mistakes will make you a better doctor.

What are the clinical years like?
This was probably my biggest question at the start of my 4th year. Clinical years are very different from pre-clinical in a number of ways. The routine of labs and daily lectures give way to time on wards, in clinics, and scrubbed into theatre. There are still occasional lectures or presentations given by students, but these become fewer and far between.

Each run is different to the next and each students’ experience is different even on the same run. Sometimes you’re with the same team for 8 weeks and sometimes you show up to a clinic with a doctor you don’t know for 3 hours and then never see them again. Each day is different too. Some days are crazy busy, others are dead quiet. Some are super long, others you’re sent home after an hour. To give you an idea of what you’ll be doing, here is what wards, clinics and theatre are generally like:

Wards
Warding involves being on the wards with the medical team you’ve been assigned to. The team will be making decisions about their care, changing medications, ordering tests or treatments and discharging well patients. You may also go on in ‘acute days’. These are the days where the team is responsible for admitting all the new patients that come to hospital under that specialty. Those patients need to be assessed, triaged by the team, investigated and have decisions made with them about their care. The patients that do get admitted this way will likely stay on your team for most of their stay in hospital.

Acute days are a great opportunity to practice clinical skills like examinations and history taking as well as take bloods, insert IV lines, read ECGs and chest x-rays, and discuss treatment of conditions. You’ll also likely get the chance to present patients that you’ve seen to the team consultant. Presenting patients is a skill in its own right, and one we don’t get nearly enough practice at, so be sure to take the opportunities you get. Presenting patients is also your best opportunity to impress your consultant, aim to present at least one patient per post-acute ward round.

Clinics
Days in clinic are somewhat akin to a GP practice. You’ll sit in an office and see a list of patients with a consultant or a senior registrar. It is a great opportunity to ask questions about specific diseases, usually in between patients. Clinics tend to be a lot more observational, but you may also get opportunities to practice some clinical skills.

Theatre
Theatre is something everyone tends to be nervous and excited for upon moving into clinical years. Getting fully scrubbed up for the first time is such a buzz, and getting to assist in theatre is a whole lot of fun. There is a lot of theatre etiquette that you’ll have to get used to, and a number of Do’s and Don’ts that aren’t really written anywhere. Some of the things that I still find really useful are:

Ask a nurse! Where do I stand? What can I touch? Is that thing alright like that? I need to do something but I am not sure about it? Ask a nurse. If you have any questions about what to do, they are always an excellent option. They’re also almost always very friendly and approachable too!

Introduce yourself and write your name on the whiteboard if there is one. Most of the theatre staff see each other every day. They are used to having people come and go, but they still want to know who that is floating around in the corner. If you introduce yourself as a medical student, they’ll often help you out and keen an eye on you in case you’re struggling or uncertain.

If its’s draped or sitting on a drape, don’t touch it! Unless you’re scrubbed in, in which case don’t touch anything that isn’t draped or on a drape.
Know about the patient Each consultant is different, but some of the worst grilling’s I have had are for coming to watch a surgery and not knowing anything about the patient. Look up the patients notes beforehand, and try arrive about 30 minutes before the surgery to introduce yourself to the patient and ask permission to attend their surgery, before they receive anaesthetic.

Another big change is that group sizes tend to be much smaller. Being with 3 other medical students on a ward starts to feel like a lot of medical students. You’ll certainly find yourself being the only medical student at times, and that can be a blessing and a curse. You will get dibs on doing or watching cool things, but you will also have to double check you got the time and place you were meant to show up correct. You will also have to get good at introducing yourself to the clinical teams you are joining, including but not limited to, nurses, allied health professionals, senior doctors, and of course the patients themselves. Being friendly and having a little bit of confidence goes a long way here. It is entirely appropriate in almost every situation to let people know who you are and why you are there, even if they do not ask.

On getting grilled…
Getting grilled is something every medical professional will experience. One day in the not-too-distant future, you will be the one doing the grilling! Grilling is almost always about trying gauge how much someone understands something while also teaching them something they might not know. You will quickly come to think of it as ‘being asked a question’ and it becomes a whole lot less of a big deal. You’ll see it happen most days, and to most of the members on the team.

The registrar gets grilled by the consultant, the house officer gets grilled by the registrar and the consultant, and the medical student gets grilled by everyone.
But you will learn heaps of practical and useful information this way, and you will come to appreciate the doctors that ask you questions instead of ignoring your existence.

When you don’t know the answer…
Contrary to TV and movies, it is impossible to know everything. The amount of knowledge out there is overwhelmingly vast and much to student’s chagrin is often not found in textbooks. You should get comfortable with saying “I don’t know”. It’s not a sign of weakness, laziness, or any reflection on your moral or intellectual character. You will be asked questions you have not learned the answer to yet. You will be asked to do things you have never done before. False bravado in these situations can not only leave you looking and feeling really stupid, but can actually be dangerous. There is also no surer way of losing people’s respect than placing your ego over safe practice. You will also find you get more learning when you say those three simple words.

Lastly…
Have fun! Clinical years are exciting, nerve-wracking, diverse and a huge privilege to be a part of. You’ll get so much more out of it if you try find something interesting or enjoyable, even on the runs you don’t necessarily like.

Other doctors will notice too and are usually way more engaged with students they can see are interested and keen.
When you do finally see your first patient, be yourself, enjoy the privilege, and relax. You know far more than you realise!

About the author
Ryan is a Trainee Intern in Christchurch hospital with a keen interest in Emergency and Intensive care, as well as teaching. In his spare time he is keen on almost every outdoor pursuit imaginable.

Correspondence
Ryan Ord-Speed: r.ord-speed@live.com