Clinical Clerkship|Explained

So you might be an incoming fourth year medical student. Or maybe a parent of one. Possibly a partner of an incoming clinical clerk? Bottomline is you’re here because you are wondering, “What is clerkship?” and all the other questions you might have.

In this post, I will be giving you guys an overview of the life of a clinical clerk as easy as I can, with visual aids to ease you into understanding it. Disclaimer in advance though, I will be discussing things based off my experience as a clinical clerk at University of Santo Tomas. I’m also not going to go too in-depth with the specifics per rotation. Keep in mind that clerkship programs will vary among the various schools, and obviously among the different countries. This is going to be a long one, so without further ado, let’s dive in.

What is Clerkship? How is it different from junior internship?

Until recently, clerkship was known as junior internship. It is essentially another way to label a fourth year medical student. This is why you may still hear “JI” from staff nurses or doctors. But unlike the first three years of med school where you sit in a classroom and attend lectures for the most parts, you’re now in the hospital, working as a clinical clerk, doing… clerical things…. in the clinic (please don’t hate me).

So… What Exactly Will I Be Doing? Will I Still Be Attending Classes?

What a clerk will be doing will vary vastly, depending on what rotation you are in. With so many different and unique rotations, it is hard to pinpoint what exactly you will be doing, but to give you an idea, I broke it down for you into 4 major categories below.


At this point, you don’t really have to know the specifics of the processes or types of papers you will be accomplishing, as it would be too tedious. It will also vary from rotation to rotation, and also between hospitals you’ll be rotating since, as most, if not all med schools will have outside rotations. Just keep in mind of the things above, so you know what to expect. It’s impossible to know everything before the start of the clerkship. You will learn as you go, don’t worry!

What do I have to Prepare?

Back when you were preparing for your second year in med school, you probably assembled your med bag, containing everything from stethoscope to coffee powder for testing olfactory nerve function. In clerkship, however, you can narrow down that things you bring on a regular basis.

So the Must Have above obviously is a…. must have. I explicitly stated axillary thermometer, because when a patient is febrile, non-conatct thermometer is often unreliable. In such cases, your superior usually asks for an axillary one. With surgical tape, I prefer Transpore over micropore. I had a mistake of buying a lot of micropore prior to clerkship and ended up not using it. It’s not as handy (especially with tearing) as Transpore, and it is not as resistant to moisture too. I personally did not use a lot of tapes during my rotation at USTH, but it came in handy when I was doing my rotation at JRMMC, where I do a lot of IV line insertion and blood extraction. I also included ball pens (yes, plural) because somewhere in every hospital, there is a Bermuda triangle for ball pens. Bring extras.

For the Nice to Have, I included power bank, especially when you are on a toxic duty. From taking notes of an initial reading of a radiological exam to updating residents on a patient’s status,I often find myself with a drained phone. While both Tuning fork and Reflex hammer are must have, it is heavy to carry around in your med bag, and you don’t use it too often. Just make sure that you have at least one in your duty group, in case you need one. Similar with tape measure, except when you are in OB-GYN. You’ll be needing it in your bag. If you can, install Medscape and/or UptoDate and download the offline contents. It will help you during your rounds and conferences.

As for the other things you have to prepare, this might be a luxury, but having sufficient number of uniforms for the week will make your life a lot easier. It is a hassle to do laundry after a toxic day. Also, always pay attention to the orientations per rotation. Each rotations would have a different system, and you will do yourself (and your group leader) a favor by not missing out on anything. I also have a pretty complete set of sleeping gears in my locker, so I can maximize my rest when I can, during my duty nights. I have eye mask, pillow and a blanket kept in a tote bag. Some quarters can be so cold at night, so keep yourself cozy.

As for other requirements for clerkship such as physical examination, and vaccinations, just be attentive to your orientation. I’m sure they will be discussing it, and the process will again vary from school to school.

What Do You Mean by the “Pre, Duty and From” Status?

This part was very confusing even to me especially during my first three years in med school, and I really got a grasp of it only when I started my clerkship, so let me simplify it for you. For the most clerkship programs in the Philippines, the clerks will undergo the continuous “Pre, duty, from” cycle for a whole year.

Let us say, it is March 1, and your status (a.k.a post) for the day is pre-duty (a.k.a. pre). You report to the hospital by 7 AM, then you are usually dismissed by 5 PM (unless there are pending tasks), then you are free for the rest of your day. The next day, March 2, you will be on duty. You will report to the hospital at 7 am, then stay in the hospital to work for 24 hours. This means you complete your duty status at March 3 at 7 AM. This also commences the from duty (a.k.a. from) status. You are then usually given a hygiene break of 30 minutes to 1 hour to take a quick shower and freshen up (unless there are pending tasks), then you stay in the hospital to work until 12 PM…on good days. There are days when you have activities and conferences, so you might have to stay longer, and that is not uncommon.

So in total, depending on when your duty status lands on the day of the week, you will be working for 83-102 hours a week, minimum. As I’ve said, there are days where you have conferences and other activities. Some days, the outpatient may extend up to 6:30 PM, instead of 5 PM. The surgery you’re assisting in might be unexpectedly long. That being said, being on pre or from status will not guarantee you an exact dismissal time. This is why I say 83-102 hours/week is a minimum. Keep that in mind, so it won’t hurt when you have to extend your working hours (but it does).

Knowing the information above will help you understand how usually a work is divided among the team mates, which I listed below.

Pre

In some rotations, you are assigned to the outpatient department, seeing patients from 7 AM to 5 PM. The dismissal time varies on the workload at the OPD. For rotations that has a specific grouping dedicated for the outpatient department, pre status will be sharing workload with the duty status at the ward, usually focusing on things like monitoring and helping out duty status in errands.

Duty

It’s your day! You do anything under the sun, but is primarily responsible for the direct patient care for the day, including but not limited to admitting patients and running errands such as laboratory and radiologic examinations. Also the one primarily responsible for checking the charts of the patients for updates, and carry out necessary orders. Obviously the one staying during the night, now also taking over the monitoring of the patients.

From

After completing the 24 hour duty, those on from status is primarily responsible for doing paperworks, such as updating the charts from yesterday’s events, obtaining signatures from doctors for completion of papers, and discharging patients. If there were errands that was not completed during their duty status, they are usually responsible for completing them.

For with status, clerks are usually required to attend conferences, with some exceptions such as if a clerk is assisting at the operating room, doing a CPR (a.k.a coding a patient), or running other important errands.

Also note that there are some variation when it comes to call time, division of work, etc. There are rotations that won’t follow the traditional “pre, duty from” cycle, such as in OB-GYN, dermatology and community medicine.

Do I Get the Weekends Off?

While you may experience having a complete weekend off in some rotations, that is an exemption and not the rule. Most of the rotations (at least in USTH) will require you to report to the hospital even during weekends. However, there’s a silver lining. In most rotations, weekends are half day for both pre and from status, leaving those on duty at the hospital.

What is a “True From”?

There are specific instances, where you don’t have to go into the “from” post. This means after you complete your 24 hours duty, and done with your endorsements to your reliever, you go home. Hence, “True from”, as in you’re from duty, and ready to go home.

So when do you get blessed with a true from? Usually on a “skeleton duty”, which usually falls on a holiday.

What is a Skeleton Duty?

So a “Skeleton duty” (a.k.a skeletal duty) happens when there’s either a national holiday, municipal office and class suspensions, or any kind of official suspension announcement. Those on duty status reports as usual, from status gets a true from, and pre status won’t have to come in at all. This would mean that all workload supposedly shared by the three posts if it were a normal day, will now be manned by those on duty for the day. Sucks for them, but not for the rest. I got unlucky and had to go on skeleton duty more than my other team mates, but it really just depends on duty schedule (including during my neurology rotation, which is notoriously known to be the most toxic rotation, and it lived up to the reputation).

Group mates? Team mates? Duty mates? What is a “Twin”?

This seems very different among various schools, so I will be discussing on how we had our groupings in UST. I made a simplified diagram below just to give you an idea of what goes down at the ward.

First, our entire batch was divided into 12 groups. I ended up in group 8, and everyone in that group are my group mates. In most rotations, you will be dividing your selves into teams, and patients are assigned to you and your team mates. So in the diagram above, Student A is on duty for the day from Team A. Student A is Duty mates with Student D and Student G for the entire rotation. While they share the same duty schedule, they mainly focus on the patients of their own team. It is common however to do a decking of monitoring at night, so everyone can get a rest. For example, Student A of Team A monitors patients assigned to Teams A, B and C for certain hours while those two rest, then someone else from the other teams take over for the next few hours. The next day, Student A will be relieved in the morning by Student B, who is on duty for that day, and so on.

If you notice, Students I and J in the diagram above are team mates and duty mates. It depends on the numbers of team in the rotation and distribution of people, but it is possible to have the same duty schedule with a team mate, and that is what you call a “Twin”. Having a twin is great because your workload is divided into half. Or you get a longer sleep while your twin is working, and you guys switch. Distributing people into teams must be strategic, as different rotations will have their unique properties, to minimize burden and maximize productivity. It is usually up to the Liason officer of the duty group to do so.

Do you get paid?

No. In fact, you still have to pay a tuition fee, comparable to that of when you were in the first three years of med school.

Is it tiring? How Much Sleep Do You Get?

This is highly dependent on your rotation. With only three more months of clerkship left, I only have community medicine (where you only report on weekdays), and pediatrics (generally not too toxic, based on what I hear) to go.

With that said, there were very toxic rotations such as general surgery, neurology and the emergency room rotation for internal medicine. However, that was not true for all, as some of my team mates never had a toxic duty during our neurology rotation, as aforementioned, known to be the most toxic rotation. There are certain people who are labeled “Toxic clerk” and “Benign clerk”, who attracts toxicity and benignity to the duty, respectively. As a skeptic, I usually don’t believe in superstitions, but this one has convinced me.

But, it definitely is tiring. There are nights where you don’t get a sleep at all because of admissions, toxic patients and whatnot, and then expected to report for a conference on the next day. On a good night with decking and uneventful duty, I would say you could get 4-6 hours of sleep maximum. But even with a (relatively, by medicine standards) long sleep, I would always find myself not that rested in the hospital.

But is it Worth it?

To be honest, it is hard to say. It would be easy for me to give a haphazard and romantic statement like “Seeing the patients get better makes it all worth it” and ignore the serious consequences it would bring.

When I was not yet in clerkship, I would hear about people quitting med school during clerkship, some, even more than half way through it. And I would always say “Sayang naman! (What a waste!). You were almost there, you could’ve just pushed through and graduate, at least.” But then when I started with my clerkship, I understood why. This one year of sleepless nights, seemingly unending work, toxic hospital culture, sick and dying patients, then juggling personal life and studies, takes a toll on you. There are mornings where I would cry because I wouldn’t want to see the hospital yet another day. And this was going to be my life for the next couple of years, even longer than med school (Unless you opted to not go into internship and not to take the board exam).

Having said all of that, for me, it IS worth it. I was lucky that, I really wanted to do medicine. I just knew no matter how hard it got, I wanted this. And it is true that the little moments make a difference, and it keeps me going for another day.

Seeing a patient go home after fighting for her life. A woman at her 40’s who had a miscarriage of her first child while, watching a young mother give birth. A sigh of relief from a family member, after stabilizing a patient. Having to turn away a patient because of lack of hospital capacity. A sincere “Thank you” from a brother of a patient who didn’t make it, no matter how hard you tried to resuscitate him. They all are little but important memories that I will never forget, and carry with me in my future practice. Being a part of these people’s lives and process gave me a sense of purpose and meaning.

Clerkship is not easy. It is not glamorous. It is heartbreaking. But it is also beautiful. It is rewarding. You give people hope. And you can make a difference in the world. If that sounds great to you, clerkship is for you.

What’s After Clerkship?

I know it’s been a long article so let me keep this short. During your clerkship, you start matching to hospitals for internship. Then you graduate, and start your internship for one year. You then take the board examination, and voila, you’re a licensed medical doctor. You then go into residency training if you wanted to, but career may vary vastly. I will be writing about it soon.

In conclusion

I know it was a lot to take in, but I think we covered things to make it easier to understand clerkship, so it is less intimidating, especially if you are an incoming clerk yourself. Once you’ve gone through a rotation, you will feel a lot more confident for the succeeding ones. If you are someone who is not a clerk, learning about clerkship for someone, I hope I was able to make it easier for you to understand the struggles that a clerk goes into. So that ends my quick overview of clerkship! Good luck!

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