Section 3: Your Role
If you are not comfortable with anything being asked of you, it is your duty to speak up. Patients deserve the best care. It is completely reasonable to expect that as a clerk on a new rotation you may need additional guidance or instruction from someone more senior than you to complete a new task.
3.1 Morning Rounds
3.2 Educational Rounds
3.3 Operating Room
3.4 Trauma
3.5 Wards
3.6 Clinic
3.7 On Call
If you are not comfortable with anything being asked of you, it is your duty to speak up. Patients deserve the best care. It is completely reasonable to expect that as a clerk on a new rotation you may need additional guidance or instruction from someone more senior than you to complete a new task.
3.1 Morning Rounds
3.2 Educational Rounds
3.3 Operating Room
3.4 Trauma
3.5 Wards
3.6 Clinic
3.7 On Call
3.1 Morning Rounds
Overview
The team of housestaff (senior resident + junior resident(s) + clerks) will review patients’ progress, conduct a focused history/physical, make the day’s plan for each admitted patient, an write a brief note.
Your Role
Overview
The team of housestaff (senior resident + junior resident(s) + clerks) will review patients’ progress, conduct a focused history/physical, make the day’s plan for each admitted patient, an write a brief note.
Your Role
- A few days before the start of your rotation, figure out who the junior or senior resident is on your assigned team – send them a text or email introducing yourself and asking when and where you should meet on your first day
- On the first day, one of the residents will likely need to be around to give you access to the patient lists. Afterwards, offer to show up 10-15 minutes early to print lists, record vitals, and gather charts – your residents will be grateful if you do this!
- Print patient list
- Annotate your list with the most abnormal vital signs in the last 24h and 24h ins/outs from the EMR or from the nursing chart (if someone had a fever but doesn’t anymore, we still want to know!). When in doubt, just ask the junior how the team likes vitals organized.
- Copy annotated list for all team members (and staff)
- Gather all patient charts
- Start the SOAP note for each chart
- Write SOAP note as the senior is talking to/examining the patient
- See section 5.2 for instructions on how to write a SOAP note
- At the end of rounds, the team will ‘run the list’ and discuss the plans for all the patients. You should copy down all the plans on your list – this prepares you to help out over the course of the day.
3.2 Educational Rounds
Overview
These come in many flavours. Grand Rounds, morbidity and mortality (M&M) rounds, tumour boards, and so on. The expectations of clerks at these rounds depend on the type of rounds and the specific hospital to which you’re assigned.
Grand rounds
often an invited speaker who gives a lecture, you just have to show up!
Tumor boards
Also known as multidisciplinary cancer conferences – here, cancer cases are reviewed, and management plans discussed. Residents and clerks may be called on to answer questions about the case. These are a fantastic opportunity to consolidate knowledge from reading clinical practice guidelines or attending clinic.
M&M rounds
Also known as quality improvement/QI rounds – here, residents typically present cases with poor outcomes/complications and the diagnosis and management decisions are reviewed. Of all the rounds, you are most likely to be asked questions in M&Ms. As a general tip when answering questions, use recognized differentials or approaches instead of simply listing etiologies/complications, and avoid saying ‘never’ or ‘always’. It's a good idea to allow people to answer questions directed at them. Even if you know the answer and are eager to contribute, chiming in out of turn can be perceived negatively.
Your Role
Very much depends on the type of rounds. See descriptions above.
Overview
These come in many flavours. Grand Rounds, morbidity and mortality (M&M) rounds, tumour boards, and so on. The expectations of clerks at these rounds depend on the type of rounds and the specific hospital to which you’re assigned.
Grand rounds
often an invited speaker who gives a lecture, you just have to show up!
Tumor boards
Also known as multidisciplinary cancer conferences – here, cancer cases are reviewed, and management plans discussed. Residents and clerks may be called on to answer questions about the case. These are a fantastic opportunity to consolidate knowledge from reading clinical practice guidelines or attending clinic.
M&M rounds
Also known as quality improvement/QI rounds – here, residents typically present cases with poor outcomes/complications and the diagnosis and management decisions are reviewed. Of all the rounds, you are most likely to be asked questions in M&Ms. As a general tip when answering questions, use recognized differentials or approaches instead of simply listing etiologies/complications, and avoid saying ‘never’ or ‘always’. It's a good idea to allow people to answer questions directed at them. Even if you know the answer and are eager to contribute, chiming in out of turn can be perceived negatively.
Your Role
Very much depends on the type of rounds. See descriptions above.
“I was temperamentally better suited to a cognitive discipline, to an introspective field—internal medicine, or perhaps psychiatry. The sight of the operating theater made me sweat. The idea of holding a scalpel caused coils to form in my belly. (It still does.) Surgery was the most difficult thing I could imagine.
And so I became a surgeon.”
― Abraham Verghese, Cutting for Stone
This quote may seem dramatic, but the idea is that if you find yourself intimidated by the idea of surgery and being in the OR, you won’t be the first. We hope that over your time in the OR you’ll have a chance to appreciate the appeal of surgery, whether or not it’s something you’ll choose as a career!
Your Role Before Surgery
Your Role During Surgery
Your Role After Surgery
Your Role Before Surgery
- Show up early! Do your best to know the patient, the procedure, and their specific management pathway/indication for OR. On your first day, this may not be possible. Ask your residents or staff where you can find the OR list for the upcoming OR day to research patients and procedures.
- If you’re attending an elective procedure, there may be paperwork you can help with – a day surgery discharge paper, a prescription for analgesia, etc.
- Go over the post-op orders with the resident or staff
- Introduce yourself to the OR personnel (staff surgeon, nurses, patient, anesthetist)
- Write your name on the board along with glove size and give your gloves to the scrub nurse
- Help transfer the patient, position them, use the clippers for hair if necessary (gather the clippers/blade and tape to take care of the loose hairs)
- Hands off the patient while they are being intubated. Generally, it’s safe to continue to help once the tube is taped in place, but you can’t go wrong by following the lead of your residents
- It is also polite to remain quiet or leave the OR to continue a conversation while the intubation is occurring
- If it looks like the patient will be receiving a Foley catheter, offer to help/learn.
- Scrub in when your senior tells you to; don’t be afraid to ask the junior or senior if you should scrub in if you don’t know
- Double glove and wear a mask with a visor
Your Role During Surgery
- You will likely be asked to retract, suction, and irrigate
- Good suctioning keeps the suction catheter close enough that the field is always clean but never gets in the way of operating. Bad suctioning allows fluid to fill the operative field and obstructs the dissection.
- Suturing and cutting sutures
- You may be asked to close skin - your residents and staff should be willing to walk you through the process, but it will benefit you to practice at home
- It can be helpful to ask the scrub nurse for the suture scissors if it looks like someone might need their suture cut soon
- If you think you may have contaminated yourself, speak up. It happens to everyone. Contamination risks infection and you have a duty to do right by your patient.
- It’s good to be eager and engaged. Surgery can be stressful, however, and during high-stress points in the operation it’s best to save your questions and do as you’re told. If you think you could be of help or have a question, ask permission first.
Your Role After Surgery
- Ensure the patient is wiped clean of any blood and fat
- Help gather the disposables and put them in the garbage (e.g. light handles, drapes)
- Ask if it’s okay to scrub out – they may have other things they want you to do while scrubbed!
- Grab the patient chart binder and write the OR note. If you’re not sure of some sections, ask the junior for help (see template)
- Finish paperwork (day surgery summary, Rx) and post-op orders if not already done
- Help move the patient from the table to the stretcher
- Ask your staff/nurses if you can help turn over the room if you’re booked for a busy operative day
- Take the patient to PACU
- Take notes on the basic steps of the procedure to help yourself learn for next time, or ask a resident to go over the steps if there’s time
3.4 Trauma
Overview
If you are assigned a rotation at either SMH or SHSC you will participate in the care of trauma patients. During the day, the Trauma Team at SHSC and the Trauma and Acute Care Surgery Team (TACS) at SMH will respond to traumas. At night, the on-call General Surgery team is responsible for all general surgery AND trauma patients. In both hospitals the trauma bay is located in the acute zone of the ED. Trauma codes are sent to a dedicated pager carried by your resident, be sure to tell them to call you when a trauma is on the way!
Incoming patients are triaged as Tier 1 or Tier 2 traumas. Generally, Tier 1 traumas are more urgent and include unstable patients and high-risk injuries such as penetrating chest wounds. The trauma team is directed by the trauma team leader, who is usually a general surgeon or emergency physician.
Your Role: Trauma Bay
Your Role: Tertiary Surveys
You may be asked to complete a tertiary survey. These are head-to-toe physical exams and chart reviews that are completed on all trauma patients 24-48 hours after admission. Ask your team where these forms are located. Do not perform tertiary surveys without confirming they are safe for you to do (i.e. patient’s C-spine has been cleared, they are stable). You must:
Your Role: Inpatient Care
Trauma patients can have many injuries and complex hospital stays. You can help your team by staying organized and having excellent attention to detail. Keep team lists and discharge summaries updated daily with injuries, consultants, plans, and follow-up appointments.
When rounding on trauma patients, closely look at ALL overnight vital signs as their condition may deteriorate unexpectedly.
Overview
If you are assigned a rotation at either SMH or SHSC you will participate in the care of trauma patients. During the day, the Trauma Team at SHSC and the Trauma and Acute Care Surgery Team (TACS) at SMH will respond to traumas. At night, the on-call General Surgery team is responsible for all general surgery AND trauma patients. In both hospitals the trauma bay is located in the acute zone of the ED. Trauma codes are sent to a dedicated pager carried by your resident, be sure to tell them to call you when a trauma is on the way!
Incoming patients are triaged as Tier 1 or Tier 2 traumas. Generally, Tier 1 traumas are more urgent and include unstable patients and high-risk injuries such as penetrating chest wounds. The trauma team is directed by the trauma team leader, who is usually a general surgeon or emergency physician.
Your Role: Trauma Bay
- Put on the appropriate PPE (lead, gown, gloves, mask) and identifying sticker (GEN SURG).
- Collect the General Surgery trauma bay forms and take notes while EMS is giving handover. Label with stickers and fill out as much as possible - recording presenting vitals is very helpful
- When multiple traumas occur at the same time, helping your residents stay organized by collecting patient labels and starting the trauma bay forms is critical.
- After you have seen a few traumas, ask your resident to teach you how to properly help with logrolling patients (with spinal precautions) and how to perform a FAST (on stable patients)
- Assist with any bedside procedures (Foley catheters, suturing, stapling, irrigating wounds, chest tubes, etc). Familiarizing yourself with the location of basic supplies in the trauma bay (saline, gauze, sutures) will make you indispensable.
- Once the primary and secondary surveys are complete, patients should be covered in warm blankets to reduce heat loss and prevent coagulopathy. Find where the blankets are and, when it seems appropriate, ask your resident if you might be able to help cover the patient.
- Most patients will go to the CT scanner after the trauma bay. Hold on to the trauma bay form and fill in the plan after the scans have been reviewed with radiology. Briefly review the note with your resident, have them co-sign the form, and drop it off in the patient’s chart, keeping a copy to give to your resident. Patients usually return to the ED after CT scans.
Your Role: Tertiary Surveys
You may be asked to complete a tertiary survey. These are head-to-toe physical exams and chart reviews that are completed on all trauma patients 24-48 hours after admission. Ask your team where these forms are located. Do not perform tertiary surveys without confirming they are safe for you to do (i.e. patient’s C-spine has been cleared, they are stable). You must:
- Examine the patient head to toe
- Check scalp for missed lacerations
- Feel facial bones for tenderness
- Inquire about vision problems, new difficulty hearing or tinnitus, new teeth malocclusion
- Otoscopic exam and look in mouth
- Palpate chest and abdomen, auscultate lungs/heart
- Thoroughly examine extremities and specifically feel for small fractures of digits that may have been missed
- Brief neurologic exam (bilateral power and sensation)
- Review all bloodwork
- Review all imaging, checking that they are final reports
- Record ALL incidental findings noted by radiologist including any recommended follow-up
- Review the tertiary survey with your resident and ask them to co-sign the form
- Drop off the form in the patient’s chart and update the sign-out
Your Role: Inpatient Care
Trauma patients can have many injuries and complex hospital stays. You can help your team by staying organized and having excellent attention to detail. Keep team lists and discharge summaries updated daily with injuries, consultants, plans, and follow-up appointments.
When rounding on trauma patients, closely look at ALL overnight vital signs as their condition may deteriorate unexpectedly.
3.5 Wards
Overview
In between ORs and clinics, you will have time to help move the service along. There’s a lot you can do as a clerk if you’re observant about the to-do list that gets put together on morning rounds and proactive about offering help. This is good practice for when you’re a resident and these tasks fall directly to you!
Your Role
Coordinate with the other clerks, junior, and senior to avoid duplicating work.
Phone calls – new consults, following up with consulting services, calling radiology/endoscopy to follow up on previously ordered investigations/treatments.
Review labs – daily bloodwork is common in our patients and is rarely resulted by the time we round in the morning. Follow-up on patient results and review abnormal/unexpected findings with your team. Make note of patients who do not have bloodwork ordered for the next day – they may need it reordered.
Review vitals
Overview
In between ORs and clinics, you will have time to help move the service along. There’s a lot you can do as a clerk if you’re observant about the to-do list that gets put together on morning rounds and proactive about offering help. This is good practice for when you’re a resident and these tasks fall directly to you!
Your Role
Coordinate with the other clerks, junior, and senior to avoid duplicating work.
Phone calls – new consults, following up with consulting services, calling radiology/endoscopy to follow up on previously ordered investigations/treatments.
Review labs – daily bloodwork is common in our patients and is rarely resulted by the time we round in the morning. Follow-up on patient results and review abnormal/unexpected findings with your team. Make note of patients who do not have bloodwork ordered for the next day – they may need it reordered.
Review vitals
3.6 Clinic
Overview
Interview patients for new consultations, routine follow-up/surveillance, and post-op follow-ups. Great opportunities to get involved in counseling and consent for procedures.
Your Role
Every staff runs their clinic differently. Some like you to see patients with them, some want you working independently from the first day, etc. Ask them how they want to run their clinic. Usually you’ll pick a chart, review the patient on the computer, perform a focused history and physical, review with staff, then dictate or type a note.
When seeing new consults, try to produce the assessment and plan yourself. This is great for your learning and transition to residency.
Overview
Interview patients for new consultations, routine follow-up/surveillance, and post-op follow-ups. Great opportunities to get involved in counseling and consent for procedures.
Your Role
Every staff runs their clinic differently. Some like you to see patients with them, some want you working independently from the first day, etc. Ask them how they want to run their clinic. Usually you’ll pick a chart, review the patient on the computer, perform a focused history and physical, review with staff, then dictate or type a note.
When seeing new consults, try to produce the assessment and plan yourself. This is great for your learning and transition to residency.
3.7 On Call
Overview
After everyone hands over at the end of the day, the on-call team is responsible for all the General Surgery inpatients in the hospital, which often means dealing with issues on the wards, in addition to taking consults and admitting patients from the Emergency Department.
Ask someone on your team to put you in touch with the junior resident on call sometime throughout the day so you can plan to meet up with them once you have wrapped everything up with your team. The resident you are on call will hold the pager and receive calls about patients on the ward and consults, triaging them to you as appropriate. If you find yourself idle, ask to take on tasks! The sooner all the work is done, the sooner everyone sleeps.
Remember that your shift ends 26 hours after you started, regardless of how much sleep you may or may not have gotten that night. If you aren’t being dismissed, you may have to remind your team of the clerk duty hour restrictions.
Finally, make sure you give your yellow evaluation card to one of the residents you worked with from each shift as they are a compulsory part of your rotation. Try to remind your resident about the form before rounds so they can budget a few minutes to fill it out. Remember that you are never bothering anyone by asking for feedback.
Your Role: Inpatient Care
The resident you are on call with may ask you to assess patients on the ward if concerns have arisen regarding their clinical status. Think about both common post-operative issues and important presentations not to miss (i.e. pain, nausea/vomiting, low urine output, shortness of breath, chest pain, bleeding, abnormal vital signs). Examine the patient, find the patient’s nurse and inquire about their concern, and report back to your resident so that you may discuss and plan investigations and management together. If you are worried about anything, call them right away.
On weekends you’re on call, you’ll be especially important to ensuring the skeleton crew get all of the daytime work done – rounding on all the patients, managing daytime issues, and discharging patients.
Your Role: Consults
You will be asked to see patients who are referred to General Surgery by the Emergency Department. When you have finished seeing a patient and gathering the relevant information to complete the consult, you will review with your resident, see the patient together, and come up with a plan. They will review new cases with a senior resident/fellow/staff and you may work together to carry out various aspects of patient care (i.e. helping with admission orders, following-up on pending investigations, re-assessing patients throughout the night, etc.).
Your Role: Taking Pages
Overview
After everyone hands over at the end of the day, the on-call team is responsible for all the General Surgery inpatients in the hospital, which often means dealing with issues on the wards, in addition to taking consults and admitting patients from the Emergency Department.
Ask someone on your team to put you in touch with the junior resident on call sometime throughout the day so you can plan to meet up with them once you have wrapped everything up with your team. The resident you are on call will hold the pager and receive calls about patients on the ward and consults, triaging them to you as appropriate. If you find yourself idle, ask to take on tasks! The sooner all the work is done, the sooner everyone sleeps.
Remember that your shift ends 26 hours after you started, regardless of how much sleep you may or may not have gotten that night. If you aren’t being dismissed, you may have to remind your team of the clerk duty hour restrictions.
Finally, make sure you give your yellow evaluation card to one of the residents you worked with from each shift as they are a compulsory part of your rotation. Try to remind your resident about the form before rounds so they can budget a few minutes to fill it out. Remember that you are never bothering anyone by asking for feedback.
Your Role: Inpatient Care
The resident you are on call with may ask you to assess patients on the ward if concerns have arisen regarding their clinical status. Think about both common post-operative issues and important presentations not to miss (i.e. pain, nausea/vomiting, low urine output, shortness of breath, chest pain, bleeding, abnormal vital signs). Examine the patient, find the patient’s nurse and inquire about their concern, and report back to your resident so that you may discuss and plan investigations and management together. If you are worried about anything, call them right away.
On weekends you’re on call, you’ll be especially important to ensuring the skeleton crew get all of the daytime work done – rounding on all the patients, managing daytime issues, and discharging patients.
Your Role: Consults
You will be asked to see patients who are referred to General Surgery by the Emergency Department. When you have finished seeing a patient and gathering the relevant information to complete the consult, you will review with your resident, see the patient together, and come up with a plan. They will review new cases with a senior resident/fellow/staff and you may work together to carry out various aspects of patient care (i.e. helping with admission orders, following-up on pending investigations, re-assessing patients throughout the night, etc.).
Your Role: Taking Pages
- Sometimes your residents may be occupied and request that you hold their pager temporarily
- Give your name and training level
- Note the following
- Reason for page (consult, ward issue, etc.)
- Patient name/location/MRN
- Caller’s name/discipline
- Time of call
- Urgency
- Never be afraid to say, “I’ll need to speak to the team about that first, and get back to you”