The blogger's misadventures: MMC Internship Orientation (and personal inputs)

A lot of soon-to-be Medicine graduates (me included) from various medical schools attended the General Orientation for incoming Interns at MMC yesterday. Seeing MMC at its full glory, one will almost never imagine that to work in such a very nice and cozy environment will be the best feeling so far. Leaving the sweatshop-like confines of the base hospitals for a cool, ideal workplace was a big adjustment for most of us. Being a former student of MMC's Nursing school, I felt anxious about everything in my "new" hospital: the new, almost-commercialised environment, the stricter, more stringent rules and regulations, its up-to-date technology, and the level of toxicity it will give to the incoming interns. I had to adjust to the fact that I wasn't returning to MMC as a Nurse, but this time, as an Intern, a fresh graduate physician who'll be getting a different kind of beating this time around.

Our orientation lasted almost the whole day. The interns were oriented about the hospital, its staff, the various departments, and a lot of other things. We were also given our schedule for the whole year. We were also given free snacks and lunch, almost ala-medical conference style of catering: a thing which we barely get to experience back during JI-ship/clerkship. We got to see and hear each and every department chairman, chief resident, intern's monitor, nursing supervisor, social service head, and even the librarian and resident chaplain, explain and describe both ends of this "big book" called MMC life. The orientation was enlightening, and at the same time, humor-filled. The good words of each department chairman speaking in front of the incoming interns gave everybody optimism that life at MMC will be unforgettable, and at the same time memorable.

Some details which were shared to us during the orientation are as follows (as far as memory serves me right):

• Attendance is usually at 7am (6:30am for Surgery and OB-GYN, 7:30am for Pedia), and sign-out is at 4pm (for pre- and from-duty status, except for OB-GYN, which sends their interns home at 11am).
• Interns get to have one day-off every 7 days
• Interns have 5-8 hours (usually 5-6 hours) mandatory rest periods for each department, usually from 12mn-5am (OB-GYN places the mandatory rest period during the from-status, making interns on from-status go home earlier than 12nn)
• The intern's ID has a microchip in it which can be used to gain access to various places. It is also used to check attendance. (just like what is being done in prominent universities)
• Community Medicine only has 5 working days. Weekends are days-off.
• Smoking constitues to termination of the internship program, (bigat ah)
• Interns get to wear 3 kinds of uniforms: the gala uniform (any formal top with white pants/skirt, and black shoes), the working uniform (the blue scrubs), and the OR/DR scrub suit. (Our outgoing Intern's Council President suggested that we wear the gala uniform during pre-duty and formal gatherings, and the working uniform during duty status.)
• Parties are held on certain occasions, and everybody even on duty status are excused from their posts when there are officially-announced events, even nightly events.
• Interns are required to complete a certain number of procedures for clearance (i.e. 10 IV insertions, 1 minor surgery, 5 NSD's, etc.). A booklet is provided for that purpose.
• Each intern is assigned to a mentor, who is tasked to guide the intern regarding career and anything under the sun
• Not attending any orientation, this General Orientation included, constitutes to 2 Sunday make-up duties, whether excused or unexcused. 
• There are so-called "star merits," which can offset any demerits from any department that has demerited an intern.

We were also given the opportunity to meet our new group mates. We were oriented by our outgoing interns about our future departments. We also assigned our individual groups different pipette colours for our OR/DR scrub suits (ours was apple green/sea spring). Most importantly, we get to know each other for a short while. (Personally, it was fun meeting new people, especially my new group mates.)

Senior Internship life is about to start in 24 days. It's about high time that each intern starts to leave that shell of clerkship and start new ground. Like what one consultant from Med. Education said, everybody starts off with a clean slate, regardless of whatever past which may have been haunting each and every intern during clerkship. This is the time to make a new name for every intern: something that is worthy of having that M.D. after each surname.

The 3 statuses of Clinical Clerkship

Dear incoming Junior Intern/Clinical Clerk,

Since we entered medical school, most, if not all of us, wondered how going on duty as an intern/clerk feels like. We would become dreadful of that so-called 36-hour duty because of fears that we might not find enough time to sleep, or maybe lose that social life that we are trying our best to balance with internship.

Recently, our batch was involved in a scuffle with the admin and consultants, wherein a certain JI sent a letter to CHEd regarding our revised duty schedule. He/she apparently called our "from" status "garbage hours" because of the observation that JI's apparently do nothing at all once they are "from" status. That incident caused a stir within the higher-ups, and because of that, a new schedule was born.

Based on the current status, here are the three duty statuses that each JI/CC must know and understand:

1. Pre-duty (7:00am - 5:00pm; 8:00am - 12:00nn Sundays)

• From the word itself, this is the status that JI's observe before going on a 24-hour duty. Pre-duty JI's are the ones who usually monitor patients in the morning up until the time they are relieved from their posts. In some departments, they also admit and deck patients to themselves if they follow the so-called "grand" decking (to be explained in a different blog).

2. Duty (7:00am - 7:00am next day, 8:00am - 7:00am Sundays/Holidays)

• This is the 24-hour duty each and every JI has to follow. This is the one of the bread and butter essentials in JI-ship: the overnight duty. Based on the new schedule, JI's on duty status start working/monitoring from 5:00pm - 7:00am the next day. The hours prior to 5:00pm for those on duty are for "in-charge" work, or for those clerks who have patients-in-charge who need to be taken care of, like working on protocols, diagnostics, etc. They are also the ones who admit patients during the afternoon until the next morning, once they are relieved by the Pre-duty clerks. In some departments, they are the ones who admit patients throughout the day if they follow the so-called "duty" decking (to be explained in a different blog).

3. From-duty (7:00am - 12:00nn; 8:00am - 12:00nn Sundays)

• This was the so-called "garbage" hours that was reported to CHEd a month ago. During the months prior to December 2012, the original schedule of the from-duty status was from 7:00am next day - 5:00pm. This status was scrapped for 2 months starting December, and was then replaced to a "once relieved" status, or in short, a "day-off" for JI's. Because of certain issues stemming from that "once relieved" status, the "from" status was reinstated in February, and this caused a stir within the JI ranks. This prompted someone to report to CHEd, and the said body acted on this issue days to weeks after the letter was received. The effect: angry and frustrated consultants, and stressed-out interns/clerks. Because of that incident, the schedule was then changed from 7:00am next day - 12:00nn. 
• This status is also called the "untouchable" schedule because those on this status are free to do anything, unless they have patients-in-charge to be taken care of. They also accept and deck patients if they follow the "grand" decking. This is the time to recuperate from a 24-hour duty by taking a bath, eat breakfast at the canteen, or read a book during spare time. After 12:00nn, they can now go home and sleep the rest of the day off, or maybe do something else.

For holidays, there is the "Skeletal" duty, wherein only those on duty status will go to the hospital and literally work for 24 hours. Those on pre-duty status need not come to the hospital, while the ones on from-duty status are relieved at 8:00am. In short, malas mo lang pag duty ka on a holiday.

Recently, some incoming freshman from a med forums page shared his discontent on the usual JI schedule. Kinda premature for an incoming med student to say such thing. Hindi mo pa nga napapasa Biochemistry, gumaganyan ka na? Tsktsk. Pero, it was his opinion, so it's best to respect it anyway.

Well, this just explains what JI's go through everyday. I hope this helps. Good luck!

The 10 most important paperworks in Clinical Clerkship

Dear incoming Junior Intern/Clinical Clerk,

Now that you've seen your name posted on the registrar's office, I'd like to congratulate you for making it to JI-ship.

Junior Internship isn't just about roaming around the hospital, seeing patients, monitoring them, and seeing them either go home or die. The most important thing, the part and parcel of JI-ship, is the tons of paperwork that are in store for each and every JI out there. That is why JI's are officially called CLINICAL CLERKS. The second word explains everything.

Clerk, the master of paperworks.

So, in preparation for your JI-ship come April 1, here are 10 important documents that you should be familiar with starting day 1:

1. Initial Summary

• This is the first document that you should accomplish, because this should be clipped in the chart within 6 hours upon admission. You should write this on the "Intern's Notes" form, which you will definitely see on your first day. There you write your patient's history and PE, all in SOAP format. Because it's "initial," this is like a rough draft of your complete database, which is explained next.

2. Complete Database

• From the word itself, this contains the whole package of your history and PE. This consists of 2 parts: the history form and the physical exam form. You fill that up based on your initial summary, wherein you try to fill in or add answers to certain questions you might not have answered during your initial summary. This should be clipped in the chart within 24 hours upon admission. 

3. Case Discussion

• This is where "the patient is like a textbook" comes in. Clipped in the chart within 24-48 hours upon admission, this contains the case of your patient that you would like to report on. From definition to treatment and prognosis, this is where you try to unravel that human textbook of yours and make a paper about it. Originally computerised, some departments might require you to write your case discussion on your Intern's Notes form.

4. Drug Charting

• This goes hand-in-hand with your Case Discussion. Also clipped in the chart within 24-48 hours upon admission, this contains the drugs of your patient prescribed to him in the hospital. It's like how you did your formulary in pharmacology: you write down the generic name, class, mode of action, indications, adverse effects, and contraindications. You can add the half-life, peak plasma time, etc., if you so wish. Bahala ka magpakatoxic!

5. Lab Flow Sheet

• Some departments, especially when you're rotating in the charity wards, will require you to clip this on your chart the moment the first lab results come in. You update that form every time a new laboratory result arrives, or if a new imaging result comes. Some residents check that sheet, and if you don't even bother making one, well you can say hello to life's big bitch slap to the face, a.k.a. demerit.

6. Monitoring Sheet

• This is where you put in your patient's vital signs monitoring and intake/output monitoring. That is one of the most looked-at sheets, because you might not know about it, but even the consultant looks at what you write on the monitoring sheet to see how their patients are doing.

7. Referral Slip

• This is the slip that you will need whenever you will refer to a different department. Departments such as Medicine, Neurology, and Surgery are big users of this slip. Here, you write the SOAP format history and PE of your patient, and along with an attached Lab Flow Sheet, you have this slip signed by your Chief Resident, and have the receiving Chief Resident see it. Once they see it, be ready to present your case. And be sure to read before referring. You don't want to ruin your day because of poor referral, trust me on that.

8. Progress Notes

• A chart essential, especially when rotating in the charity wards, this contains what has happened to your patient or your group mate's patient throughout the 24-hour duty. This is written in SOAP format. Some departments are dead strict when it comes to this, so do not forget to update your Progress Notes everyday...unless you want to be bitch-slapped (if you know what I mean).

9. Endorsement/Take-Over Notes

• Aww, and it seems like you will be moving to a new department, or maybe a new sub-rotation. If so, then this is the form that you need to make before passing the baton to the incoming JI who'll be taking care of your patient. As the outgoing JI, you make Endorsement Notes in SOAP format, and if you're the incoming JI, the same goes with the Take-Over Notes. Residents check on this, too, so be on your toes with this one.

10. Discharge/Mortality Summary (DS/MS)

• And now your patient has to say good-bye to you, either dead or alive. If so, then this is the last form that you need to clip in the chart before the patient goes home or to the morgue. This contains the components of your Complete Database, plus all laboratory and imaging results, the course in the wards, and the take-home/discharge instructions. In the charity wards, you are required to give an extra copy of the DS (without the course in the wards) to your patient for follow-up purposes. You have to have this signed by your PGI and resident. Remember: you need to have at least 25 DS/MS in order for you to be cleared by the Records Section. But, because of the big number of your batch, I'm hoping that they will decrease the requirement to less than 25.

There are still other forms that are not discussed here, but for now, these are the essential ones that you must know once you step inside the halls of the hospital.

Good luck!

The 10 things a Clinical Clerk should know

Dear incoming Junior Intern/Clinical Clerk (JI/CC),

It's about 10 days to go before your "normal" life takes a twisted turn.

I'm sure that most, if not all, are anxious on how JI or CC life, as how some of us call it, is like. The life of a junior intern, also known as a clinical clerk, is not as daunting as you might expect, and it is not as wonderful as you might imagine.

To go straight to the point, let me share to you 10 things you need to carry on once you start wandering the hallways of the hospital and start becoming the future doctor that you are:

1. Love what you do

• You will be scattered throughout the corridors of your hospital for the next 365 days. Loving what you do will give you the motivation to work hard and do your best. Do not perform tasks with a heavy heart. There will be times that you will regret doing what you are doing every single day. Just remember: loving your work is like loving your patient, and also loving yourself. So show some heart and work that ass off!

2. Learn from each patient

• When you are decked with a patient, treat each patient with utmost care, like how you would like to take care of your loved ones. But, most importantly, learn from them, like you're reading a textbook. Each patient carries a unique case that you might have read from your previous years. Internship is the time to reinforce those tiring coffeehouse sessions with real-life scenarios.

3. Take criticisms in a constructive way

• Being a JI/CC isn't all glitz and glamour. There will always come a time when you will be subjected to criticism and embarrassment. When that inevitable moment comes, try not to frown. Though it is human nature to be sad, just do so for a while. Then, when you get back to your senses, take it as a means to improve yourself. Almost all of us went through that phase, so don't think that you're alone.

4. Be nice to everybody

• Like what I've said, you will be scattered throughout the corridors of your hospital for the next 365 days. And with that comes a good attitude. Remember to be nice to everybody: from your friendly janitor up until your terror consultant. Show some love to your co-JI's, residents, nurses med techs, and a whole lot more. Your attitude will speak of how you will be seen by everybody for one whole year, so don't risk being a jerk and acting like one.

5. Treat demerits as life's painful lessons

• When life gives you accolades, it also gives you heartbreaks. That is how it goes with demerits. A demerit is life's big bitch slap to your face, telling you to man up and do better next time. Don't sulk over a demerit, because you WILL have to serve them eventually. Take it with a grain of salt: don't take it literally. Instead, learn from it, and let it teach you to become a better doctor.

6. Do not be late

• Gone were the days when we can go to class 30 minutes before it ends, and get away with it smooth and clean. It NEVER works that way in JI-ship. When attendance is at 7:00AM, do come earlier than that. Trust me, you won't like being crossed out. Three (3) strikes is equals to a 24-hour demerit. Succeeding lates is tantamount to additional 24 hours. Ain't that a bitch.

7. Know your role, and stick to it

• When you are given a role, or a certain function, live with it, and don't go overboard. When they tell you to monitor a certain patient, don't go doing other stuff not related to your assigned task. Going overboard incurs certain consequences that, mind you, you do not want to face. Know your job description, do it, and if they give you another task to do, make sure it is justifiable, and do it. Don't work on something that will implicate you into something bad. 'nuf said.

8. Know what to prioritise

• Patients are always first priority, no doubt about that. But in between patients, there will always be a #1 priority. Know who and what to prioritise. Identify tasks that are needed to be done immediately, and know which patient needs closer monitoring. It helps you save time and effort despite the unbearable load of patients that you will be having.

9. Share what you know, and learn what you don't know

• There will always be rounds with either residents or consultants. Stay alert: if you know something, and the senior asks something about it, share it with everybody. It will not make you less of a person if you get it wrong. If you don't know what is being asked, don't let it slip through your head. Learn what is lacking, and take it as a golden opportunity to learn something new.

10. Treat every single day as a blessing

• JI-ship is a roller-coaster ride. There will be days that you will love what you're doing, and there will be days that you would wish you would've quit while you still can. Take each day in JI-ship carpe diem: seize each day and treat it as a blessing. Don't treat each day as a "this again?!" moment. Each day is a blessing, so never forget to thank God for each and every day that you will live as a JI, because as a day passes by with you feeling fine, there will always be someone who's life is on the thinnest line.

Our batch's run throughout this whole JI-ship thing has been unforgettable. It taught us how to become better than what we were before. We started out as zombies, knowing nothing and treating everything as hieroglyphics. Now, we can say that we are confident to be exposed to the world of the sick and suffering. We do hope that you will become better JI's than we are. It's just a mix of a good attitude and positive outlook that will take you to better places in the near future.

Good luck, incoming JI/CC. See you in a few days! :)

Medicine: 4 years later

Four years...

How fast time flies...

It was back in 2009 when college life ended for me. It was a time when the dreams of becoming a medical student was a fresh one. It was a time when I left the comfort of my hometown to venture into another city to reach a dream some people say only a few can achieve...

To become a Doctor of Medicine..

It was the first two weeks of medical school when I first tasted the reality of medical school, that it was more hard than college life. Later, there was that temptation of quitting. For the first time in my life, I felt sad because I entered medical school without looking at how hard it was to become a doctor. My parents were very supportive of me, even encouraging me to just have fun in medical school, and quit if I cannot take it anymore.

I guess I had to give it a try. So I began to walk the road less traveled back in..

First year.

First year medicine was memorable, for it was a time that I gained new friends and gained new knowledge beyond the bounds of Nursing. There were those usual ups and downs, such as failing examinations, being involved in misunderstandings with friends, arguing with group mates, and a lot more. But, it was in freshman year that I learned that medical school can fly so fast. So fast that in a few months time, I entered...

Second year.

Second year medicine was the most chill of the 3 year levels except 4th year. It was true when our preceptor said that it was the easier than the 1st and 3rd year. I met new friends, who would later become my buddies until now. It was that year when I learned the basic skills of the physician. It was similar to Nursing, but it was more in-depth. What made it memorable was that t was in second year where I met a simple, down-to-earth girl, wherein I became so much comfortable with her, my emotions couldn't control my rationality. Our friendship eventually led to a better friendship, but it later ended up in a sad turn. That of which happened during...

Third year.

Before I even talk about that, third year was the most stressful because it was the preparation for Junior Internship/Clinical Clerkship, or fourth year. It was then when I felt so stressed, that there were times that I would have bouts of mental and emotional breakdowns, up to the point of entertaining thoughts of quitting again. My solace that time was teaching kids Bible stories on Sundays, and most especially, spending time with the girl I met back in second year. About her, she was just the comfort from the stress, the happiness that made me smile despite the sea of sadness. It was that year, during that cold November evening, when my college past caught up with me, and our friendship got strained completely. It was a emotional downward spiral for me, in which the thoughts of her keep on catching up with me until internship.

But enough of that. Third year was a bumpy ride, wherein I thought I would fail some subjects, that I wouldn't be able to make it into internship. The months that ensued during third year had my anxiety levels increase to insurmountable levels because of the uncertainty of becoming an intern. But, during that chilly March evening, I learned the greatest news: I was promoted to...

Fourth year.

I have to admit, fourth year, or Junior Internship (JI)/Clinical Clerkship (CC), has been the BEST thing that has happened to me. It was this year that I felt like a doctor. Admit it or not, this is the year where we start from the bottom of the medical totem pole. It's true about what someone told me before, that internship unleashes the 'natural' in you. It was here that I learned about the true nature of people, the 'real' them in the face of reality. On the bright side, it was in internship that differences were settled, and friendships rekindled. It was here where the textbook learnings sprung to life. It was here where we learned to keep our emotions to ourselves whenever someone dies right in front of our eyes. It was here where we were given demerits, where were learned the pains of being scolded at and being embarrassed in front of a lot of people. It was here where we met new people in the form of friendly residents and staff members. It was here where I met new people. It was here where....

Okay, enough of that.

After so many years, it all boils down to the last few weeks of internship. Much as I want to tell my medical school story in detail, it will not be enough for 1 post to share it all.

I just wanna graduate.

I really want to become a doctor.

It'll almost be over. It's just these eyes on the prize.

Almost there

For the past 10 months now, my life has been living on a series of events which I can vividly enumerate:

1. Wake up before 6AM, even before the alarm hits.
2. Reset the alarm and sleep for another 5 minutes.
3. Wake up feeling so frustrated, begging for another round of sleep.
4. Prepare for half an hour (breakfast included), then head off to the hospital.
5. Drive for 20-25 minutes through the bustling traffic.
6. Make it to the hospital, work my bum off for 10-34 hours, depending on the schedule.
7. Go home, driving another 20-25 minutes feeling all groggy and sleepy.
8. Make it home, use whatever time is left for myself (surf the net, watch a movie, read notes, etc.)
9. Sleep for 5-6 hours, depending on what time I doze off.
10. Repeat.

Yes, repeat.

That is how my life as a Junior Intern/Clinical Clerk has been going. It has been like this for such a long time, I sometimes forget what day of the week it is.

It makes me reminisce how much I miss the life of the classroom: its ambiance, listening or sleeping through lectures, going home and study, and even going out.

Back then, I was in command of my time. I almost had every minute for fun.

When the calendar struck April 1, that life became a thing of the past.

Everyday has been a struggle. The sight of patients and staff, and the sound of endorsements greeted me every morning as I arrived at the hospital. My day would run monitoring patients, referring left and right to different departments, doing chart rounds, attending conferences, and sometimes get my bum kicked for some incursions. That would end as the sun begins to set, sometimes leaving the hospital at night because of unfinished tasks.

I then sometimes become envious of other people, who get to enjoy their lives, having control of their own time. I couldn't help but wonder how I can use up the remaining hours of the day to make my own day worth it.

It's a sad thought, to be honest. But it is a reality that I chose to live. For me, it's a blessing to be in the hospital, despite the hardship. It's a moment for me to realize and appreciate the importance of life and health.

What makes a day in the hospital worth the hard work is when a patient says "Thank you" with a smile on his/her face. Those 2 words and that nice expression never fails to erase a day's worth of stress.

It's almost 50 days to go before this present life of mine draws to a temporary close. I can't wait for vacation to come, to have time for myself, my family, and loved ones (friends included).

Most especially, I cannot wait to graduate.

"Almost there." That is what is on my mind right now.