"Nuts & Bolts 2" - A Guide to the Clinical Years Section 3: Insider's Guide to Inpatient Settings Table of Contents Call Schedule "Call nights" refer to the times when you admit patients to your ward team. They extend over 24-hour periods every three to four evenings. Interns take turns admitting patients. As a third-year medical student, you will often see patients initially with the intern and then spend extra time collecting sufficient data for your own work-up (i.e., extra history, more thorough physical examination). Not all clerkships require that you stay overnight, but surgery and OB-GYN will require a stay at certain sites. On other third-year clerkships with calls, students can usually leave between 10 P.M. and midnight. The Cast of Characters The Attending: Attendings are (a) clinical faculty: full-time clinical faculty members or doctors with private practices who come to the teaching hospital as an attending one or two months per year; or (b) academic faculty: people who primarily do research, but also attend a few times a year. They "attend" over ward teams and are often in charge of didactic teaching. On medical services, the attending will usually be there four to five times a week (or more), often in the morning for several hours. This is essentially the only time that you will interact with the attending. You should ask important questions about your patients, and especially ask for feedback regarding your presentations and write-ups. It's helpful to photocopy your write-ups for attendings. Attendings are ultimately responsible for the care of each patient on their ward team. They review treatment plans, write brief notes in the chart, and are responsible for didactic lectures. The Hospitalist: The hospitalist is a physician who spends more than 25 percent of his/her time based in a hospital setting, serving as the physician-of-record after accepting "hand-offs" of hospitalized patients from primary care physicians (PCPs), returning these patients to the care of the PCPs at the time of hospital discharge. You should interact with the hospitalist as another attending. The Fellow: Fellows are individuals who have completed residencies and are continuing in a given area of subspecialty. Medical students work with fellows only on consult services and in fourth-year intensive care clerkships. The Resident: Residents supervise ward teams. Since they have at least one more year of experience than interns, they will help formulate patient treatment plans. They are the primary teaching source for medical students. They are also a terrific source of feedback, and will likely participate in your evaluation. Residents are referred to as "R2", "R3"... "R7," depending on their year of post-graduation. On medical teams there is usually a single resident (R2 or R3) and on surgical teams there is often a junior resident (R2), senior resident (R5 or R6) and chief resident (R7). The Intern: Interns are the cogs that make hospital machinery move. Many interns come from non-UCSF programs and will be unfamiliar with the hospitals (just like you) at the beginning of the year. However, the benefit of two years of medical school clinical experience makes them more comfortable in the hospital setting. They take turns admitting patients, writing all of the notes (admission notes, SOAP notes, etc.), and performing almost all of the procedures (blood draws, lumbar punctures, etc.). Interns can sign prescriptions for medications in the hospital, but cannot sign prescriptions to be filled at outside pharmacies until they pass the U.S. Medical Licensing Exam Step 3 (at the end of their internship). Medical students work with interns on the wards and share the responsibility for patients with them. The Fourth-Year Student: Fourth-year students are "subinterns." They share responsibilities and alternate with the intern in admitting patients. Typically, they follow separate patients than third-year students, allowing both to have similar learning experiences. They are part of the call schedule and must stay overnight in the hospital on their call nights. The Third-Year Student: The third-year student is the equivalent of an information sponge. On the medical ward team you will work in conjunction with the intern and the resident. When a patient is admitted to the hospital, all three of you will see the patient (in addition to anyone who saw the patient in the emergency room). It is a good idea to see the patient initially with the intern or the resident and spare the patient repeated histories and physical examinations. All three of you will write admission notes. From then on, you will follow the patient and write the daily notes instead of the intern. The intern and resident will work with you to formulate your treatment plan. In terms of procedures, you will learn to draw blood, start IVs, do lumbar punctures, etc. Don't worry about getting a chance to do all of these procedures right off the bat; everyone gets ample opportunity during the third year. Your goal is to know more about your patient than anyone else. However, it is sometimes difficult to be the most up to date on your patient, because other providers may communicate information about your patient directly to your intern or resident. Ask your intern before/during rounds if there are any new events. Also ask the nurse following the patient and check orders. Then, still be ready to be interrupted and have the information change. Be flexible and do not get discouraged. Your classmates are one of your greatest resources for learning and support. When paired with other students, in order to maximize everyone's experience, please observe the "Golden Rule" of clerkships: Always interact in a way that you would find acceptable if it were applied to you.