The Clerkship Guide

THE
Clerkship Guide
The unofficial UBC Medical School sur vival

guide to third and four th year
Leslie Anderson
Andy Chen
Maggie Eddy
Aaron Gropper
Christine Kang
Design: Chanel Kwok
TABLE OF CONTENTS
Contributors.......................................................... 1
Welcome to 3rd Year!.............................................. 2
The Basics............................................................. 4
Documentation..................................................... 26
How to Operate in Surger y ..................................... 48
Wellness.............................................................. 64
Sites: VFMP........................................................ 76
Sites: SMP......................................................... 102
Sites: IMP.......................................................... 107
Rotations........................................................... 114
Year Four: Electives & CaRMS .............................. 205
Thanks for the Read!........................................... 217
The CLERKSHIP GUIDE | Table of contents
CONTRIBUTORS
Writers
Leslie Anderson, MD 2013
Graeme Bock, MD 2014
Andy Chen, MD 2013
Erica Chhoa, MD 2014
Sabrina Eliason, MD 2013
Jessica Fong, MD 2013
Aaron Gropper, MD 2013
Benjamin Jong, MD 2013
Sally Ke, MD 2014
Edmond Li, MD 2014
Anne-Marie Madden, MD 2012
Serge Makarenko, MD 2013
Clara Westwell-Roper (MD/PhD Program)
Editors
Erica Chhoa, MD 2014
Jackson Chu, MD 2014
Maggie Eddy, MD 2013
Lawrence Haiducu, MD 2014
Christine Kang, MD 2014
Diana Kang, MD 2014
Rachel Lim, MD 2014
Julie Man, MD 2014
Harman Parhar, MD 2014
Ben Tuyp, MD 2014
Andrew Wong, MD 2014
Charlie Zhang, MD 2014
Design
Chanel Kwok, MD 2013
The CLERKSHIP GUIDE | Contributors
WELCOME TO
3RD YEAR!
Written by Leslie Anderson, MD 2013
Edited by Andrew Wong, MD 2014
This year is what youve been waiting for - to be in the hospitals and clinics
working directly with patients as a useful part of the health care team. You
probably wont FEEL useful at first, but rest assured that as the year goes on, you
will become more and more comfortable with your role and will be contributing
in an increasingly meaningful way. The learning curve starts out steep, but trust
us, things will start to stick. Youll start to develop your own way of approaching
tasks and your own style of medicine. Hopefully, you will also find that magical
specialty to fall in love with if you havent already!
As youve heard, third year is going to be a challenge. The hours are long and you
need to find time to study for the exams that come up every few weeks. Some
mornings will start really early while others can end quite late. Be prepared to
spend up to 28 hours straight working a call shift. You may also come up against
difficult moments with patients or colleagues, or make mistakes that make you
feel stupid, and youll probably have days where you come home, burst into tears,
and wonder why you ever thought going into medicine was a good idea.....
But, thats okay! Weve all been there. Its tough. But its also rewarding,
interesting, and amazing. Youll get to watch peristalsis happen before your eyes
in general surgery. Youll learn to figure out whats causing your patients
acidosis. Youll offer comfort to people that are breaking down from their own
frightening health-related experiences. This year is YOUR chance to jump in and
try it all while you have ample support backing you up, to become the best doc
you can possibly be. So when it seems like all the odds are stacked against you
and the walls are caving in, focus on all the great things youve seen plus the
awesome work youve accomplished and plow right on through!
This guide was created by the Class of 2013 in the hopes that we can make Third
Year a little less intimidating.
Good luck, and hang in there!
The CLERKSHIP GUIDE | Welcome to 3rd Year!
A special note to the brilliant students studying outside VFMP: Although

we did our best to all information regarding UBC Clerkship, we were
unable to gather some specific information for sites outside of the VFMP.
You have not been forgotten! We are working hard to make sure that this
information is included in the next edition of the clerkship guide. Because
all of the information comes from students, if you are studying in
Chilliwack or Kelowna or Victoria or anywhere outside of the VFMP, we
welcome your advice!
The CLERKSHIP GUIDE | Welcome to 3rd Year!
THE BASICS
Written by Leslie Anderson and Andy Chen, MD 2013
Edited by Andrew Wong and Diana Kang, MD 2014
How to choose and rank your track..................................... 5

Valuable pearls from 1st and 2nd ......................................... 7
What third years wished they knew ...................................... 8
How to prepare for clerkship ............................................... 9
Best clerkship smar tphone apps .......................................... 12
How to study during clerkship ........................................... 13
Is a car necessar y?........................................................... 14
Impor tant pearls of advice................................................ 15
5 things to take FULL advantage of ! ................................... 17
Ten moments that will happen in 3rd year ........................... 19
The CLERKSHIP GUIDE | The Basics
How to choose and rank

your track
There are lots of different schools of thought when it comes to deciding which tracks to rank
highest. Generally, people are happy with what they get, regardless of the order the rotations fall
into, and things work out in the end. But, there are a few things one could consider when ranking
track choices.
The biggest decision tends to be whether to do the Big 3 (internal medicine, surgery, and
pediatrics, which are 8 weeks each) first or last. Here a few things to ponder as you make that
major choice:
BIG 3 FIRST: PROS
You get them over with! Oh baby! There is a wave of relief and much less stress after the
halfway point!
Usually students are keen and fresh at the beginning of the year, meaning they have more
energy for these intense and long rotations.
Doing both medicine and surgery early can help you figure out which umbrella of specialty
you fit best under if youre still not sure.
You get a great, broad background to help you in the other rotations. Nothing feels scary or
foreign after youve learned how to consult patients, admit them, and manage the wards.
The long duration of the rotations allows you time to figure out how the hospital works
and where everything is at the major hospital sites and still have time to get a lot out of the
rotation, whereas if you start with a rotation that is one or two weeks long, youd waste a
lot of time just figuring out what to do.
BIG 3 LAST: PROS
You get to work up to the big rotations instead of jumping right in, which means youll feel
more prepared and less overwhelmed. You can use the first half of the year to study in
preparation for the big 3.
Starting with the smaller rotations allows you to explore more options before 4th year
electives need to be chosen.
Youll be doing the big 3 during the longest hours of summer which means you wake up
refreshed to the sunlight and possibly leave the hospital with sunlight, so you can still enjoy
some of the evening outside.
A FEW OTHER THINGS TO KEEP IN MIND
If you have a good idea of what youd like to do, most students recommend aiming for a
track that puts that rotation midway through the year. That way, you have enough
experience on the wards to make you look good, but its also early enough that if you
discover you dont like it as much as you thought, theres lots of time to change your 4th
year electives.
Doing internal medicine before surgery can be very helpful, since the written exam for
surgery tends to involve many internal medicine topics.
The learning curve on your first rotation will be quite steep as you figure out what youre
expected to do, how the wards work, how to write orders, etc. so you might want to start
with something you know you have no interest in. That way, you wont be as stressed out if
you mess up a lot!
If youre trying to decide between a couple of specialties, doing them earlier in the year will
help you figure out which direction you want to go in before its time to choose 4th year
electives.
Obs/Gyn can be a difficult and tiring rotation (essentially making it big 4), so some
students decide they prefer to keep this separate from the big 3 to have a bit of a break (ex.
tracks B/C)
Return to: Table of Contents
Valuable pearls from 1st and 2nd

year to take into 3rd year
Your physical exam and history skills are crucial - many times, your assessment will be
trusted as accurate and wont be redone by a resident or attending, so make sure you know
what youre doing. Having said that, however, make sure you always admit when you dont
know something, or if you forgot to ask or examine something. Never make up
information!
Having an approach to problems is very helpful. In PBL, you use VINDICATE and that
approach can be applied to pretty much anything, but as you go along, youll pick up other
approaches as well. Sometimes its helpful to go by systems (such as in chest pain), while
other problems require a more anatomical approach (like abdominal pain). Whatever you
end up using, having a good approach that makes sense to YOU is key!
You will write SOAP notes every day, so make sure you understand how to write them well
(see the Documentation section).
Antibiotics will be used in almost every rotation. Knowing which ones are most commonly
used for the major issues (pneumonia, UTIs, skin infections, meningitis, preoperative) along
with the most common bugs that youre targeting in those infections will be very handy.
Have an approach to chest X-rays and ECGs, as you will encounter a lot of them!
Professionalism is important. Make sure to carry forward the habits you developed in
Clinical Skills - dress appropriately, treat people with respect, show up on time. The
principles are simple but they make a big difference.
Overall, remember that you have learned well and know your stuff. You will be fine!
Dont miss: What third years

wished they knew going into
Clerkship
Its okay to not know things. The whole point of 3rd year is to learn - if you already knew
everything, you wouldnt need to be here!
Pretty much everyone feels like they failed the NBME written exams, but virtually
everyone still passes.
Let the attending physicians and residents know what level youre at and what point of the
year youre in, because they dont always know and if they realize that youre just starting
your 3rd year, theyre more likely to go easy on you.
Its okay to let your residents and preceptors know if you already have a specialty that
youre hoping to go into. A common myth is that people will ignore you or not call you to
see interesting things if you tell them you want to go into a specialty different from theirs,
but, in general, people actually tend to be really supportive. Often, they will try to give you
patients that are more related to what youre interested in, so its completely fine to be
honest, as long as you are respectful of the specialty youre in. Also, if youre interested in
family practice, no doctor has yet to criticize this career option, as everyone knows we can
always use more GPs!
Study as you go. You cant leave things until the few days before the exam because theres
way too much to cover!
How to prepare for clerkship
Make the most of your rural rotation. Start reviewing major topics (heart problems are a
good place to start), read around your patients, and take advantage of every opportunity to
learn a procedure. Start getting a feel for writing in charts and writing prescriptions/orders.
Rural is also a great time to start trying to come up with your own plan for the patient.
Even if youre completely wrong, your preceptor will appreciate your efforts and youll end
up learning a lot more than if you just let them tell you what the plan is!
Go over major topics that will be helpful during 3rd year with your friends. Good things to
review include antibiotics, ECGs, chest X-rays, and your histories and physicals for major
complaints (some very common things youll encounter are chest pain, shortness of
breath/cough, abdominal pain, and decreased level of consciousness). Although, if you
dont want to do any review or dont have the time, thats okay too - you can do some
review during rural, or just go with the flow once your rotations start. Youll be fine either
way.
Once you know which hospital youll be at, taking a quick tour can help ease anxiety and
avoid tardiness on the first day, since youll know where things are.
Talk to people in upper years about what to expect. Most of them will be happy to pass on
tips and advice.
Take some time to clean your house, organize your desk, and get everything ready for a
year of studying. Stocking up over the summer on toilet paper, toothpaste, and whatever
else you need on a daily basis means less worry about getting to a store during your
rotations. Having quick meals in the freezer is also helpful.
Enjoy your summer and relax! Make the most of the time off, as it will be a long time before you
get such a long break again.
WHAT TO DO ON DAY ONE OF YOUR ROTATION

Most rotations will have an orientation and youll get an e-mail telling you where to show up on
day one. Make sure you introduce yourself, let people know where you are in your training, and
maybe ask for a quick tour of where youll be working (if you dont automatically get one with
your orientation).
WHAT TO BRING (AND HOW TO CARRY IT ALL)

A general concept to keep in mind during rotations is to bring as little as possible to the hospital,
for both security and convenience. Sometimes you will have a locker with enough room to
securely store a big backpack, but sometimes you wont, so youll want to keep things simple. A
few things you should probably always keep with you are:
Your ID (both your hospital ID and your legal ID, like a drivers licence)
Money and/or a credit/debit card
Your phone*
Pens
A granola bar
*One exception to having your phone with you is in obs/gyn at BC Womens hospital - they dont let you
carry one with you. And, of course, in every rotation, keep in mind that its really unprofessional to be
checking facebook while youre supposed to be working/learning.
Even when youre in the OR and wearing scrubs, those things should fit in your pockets. The rest
of the time, most students use and recommend a smaller messenger-style bag that can be carried
with you without getting in the way too much. Backpacks are really cumbersome, so lugging one
around with you is not recommended.
If youre at a site that provides a locker to you, by all means bring a backpack with a lunch, a
water bottle, study books etc. As you go through third year, youll get a feel for what you need
and youll probably find that you carry around fewer and fewer items. What you need will also
vary by rotation, and there are some specifics in the rotation sections below.
For call shifts, you will often have a locker, but try not to bring anything irreplaceable in case you
leave your bag behind. A few things you might want to bring with you for call shifts include:
10
toothbrush & toothpaste
deodorant
hairbrush
small hand towel
extra socks/underwear (youll probably be wearing scrubs, so you dont have to worry
about other clothes)
an extra sweater or small blanket (the call rooms can get REALLY cold, so its nice to have
something extra that is cozy... you can also usually grab extra hospital blankets from nearby
shelves if you needed)
FOOD! And lots of it! (Dont forget something for breakfast!)
study materials to read if things are quiet
HOW CALL WORKS

Generally speaking, your schedule for third year is Monday to Friday, 8 am to 5-6 pm (the start
time may be earlier for rotations like surgery, and possibly a bit later for others like psychiatry,
and you may occasionally work later than 6pm depending on what youre doing and where you
are). However, for some of the rotations (the big ones, to be exact), you will also be on call. The
frequency of call varies by rotation and site, but the concept is basically the same.
On the days youre on call, if its a weekday, you will work your usual day with your usual
rounding/note writing/patient care/etc. But, throughout the day, you may also be called to do
consults, where you will get a history and do a physical exam on a patient that your service has
been asked to see (usually in the emergency room, but not necessarily). Afterwards you will
review the patient with either your resident or attending, and will come up with a plan together
(ex. admit to ward, urgent surgery, outpatient follow-up, etc). Your call shift will extend beyond
your usual end time and you will continue to see consults throughout the evening and sometimes
overnight. You may also be called for issues on the ward. If things slow down a bit, you might be
able to get some sleep. In the morning, you will usually meet up with your team/attending and
may round on patients or (if youre lucky!) get to just go home. Most residents and attendings are
good about getting you out when youre supposed to be finished call, but be prepared to have to
put in a little extra work if the need arises. For call shifts on the weekend, you may have a slightly
different start time than during the week (although you will still start your shift sometime in the
morning), and you wont necessarily do the same daily activities you would normally do on a
weekday. Instead, you may do a quick rounding on patients and/or you may just be waiting
around for consults or ward issues. When it comes right down to it, on call is basically another
name for really long shift.
HOW TO BE A PART OF YOUR TEAM

The easiest thing to do to be part of the team is to be pleasant to work with. Be respectful and
polite, and show interest (even if you really hate the specialty youre doing!). It will make a big
difference.
Aside from enthusiasm and courtesy, get a sense for what needs to be done throughout the day
and start getting tasks done without being asked. Some simple things that you might be able to do
include printing out a patient list for everyone in the morning, checking your patients charts
before rounds so you can ask about any issues that came up overnight, and writing orders/notes
in the patients chart during rounds to save time later (although make sure you get a sense for
how things run before doing this, because some residents/attendings may not want things written
as youre talking to the patient).
11
Best clerkship smar tphone apps

Medscape (Free) - A general disease reference that has quite a bit of information for free
UptoDate (Free on your phone, but requires a paid subscription) - Handy if you already subscribe
to UptoDate.
BC Guidelines (Free) - The app is simple, but includes guidelines for common problems
(diabetes, asthma, chest pain, etc.) in BC.
Diagnosaurus ($1.99) - Great for jogging your memory about the differential diagnosis for a
whole slew of symptoms.
KidNorm ($2.99) - Full of pediatric lab values, developmental milestones, and tons of other kidrelated resources.
MD On Call ($4.99) - A quick reference to remind you of what to ask and what the differential is
for common problems youll be called about when youre on call
Medical Abbreviations by QD Ideas ($0.99) You may know that AMA usually means against
medical advice but did you know it means something totally different in obstetrics (advanced
maternal age)? Avoid embarrassing moments with this handy app on medical abbreviations
Epocrates (Free) - A good drug reference, and the basic version is free. The only downside is that
it doesnt include Canadian drug names (an alternative with Canadian names is Tarascon-$39.99)
Calculate by QxMD (Free) - Do a whole bunch of common medical calculations just by plugging
in the numbers. (an alternative is Mediquations for $4.99)
LabDx ($9.99) - Explanations of various lab results. (An alternative is Medical Lab Tests - $2.99)
PEPID (Free for basic version) - A toxicology & antidote resource.
ECG Guide by QxMD ($0.99) - Has an ECG reference, samples, and a quiz.
iMurmur ($5.99) - You can listen to real heart sounds to brush up on your auscultation skills.
Nerve Whiz (Free) - A great reference for neurological problems - you tell the app where the
person is weak or having sensory problems and it tells you what nerves are involved.
iBook/DropBox/SkyDrive etc for storing pdfs (Mostly Free) - Having some way to store and
view pdfs on your phone is very handy for studying on-the-go.
Mental Note ($2.99) - Great for taking notes or storing the many call room door codes!
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How to study during clerkship
Read around your cases - the information tends to stick better and have more relevance!
Keep a notebook with you so you can jot down things to look up later.
The focus becomes less on physiology and more on approaches and management, so you
may need to adjust your studying to accommodate that change.
Make the most of your clinical time by seeing as much as you can and asking lots of
questions.
Take advantage of academic half days and teaching sessions, both formal and informal.
Ask your residents questions!
Find a set of review books that you like (First Aid, Blueprints, NMS, etc) and try to read
through the whole book during your rotation.
To keep on track, creating a study schedule may be helpful. Make a list of objectives
and/or topics you need to cover and work out how much you have to read/study each day,
then do your best to keep to the schedule. Schedule in some break time, too, though!
What youre studying during third year is the information youre going to need on a day-today basis as a physician, so find a way to study that really helps you absorb the information
and start to develop a way of approaching problems that is effective for you.
13
Is a car necessar y?
Maybe. This is a difficult question to answer because it depends largely on where you live, where
your rotations end up being, and how much of a commute you are willing to tolerate on the bus
or a bike. Having a car certainly can make third year easier, but if you dont want the hassle or
expense of owning a vehicle, students have made it through the whole year without one. If you
live in the VGH area and/or live near a B-Line bus stop or Skytrain, youll probably be fine
without a car. Take advantage of the rotations where you are given a choice of location and
request a nearby hospital as soon as you receive the e-mail. Keep in mind, however, that many
rotation locations are randomly assigned and you could be as far away as Peace Arch Hospital,
which will be a challenge to get to without a vehicle. Joining a vehicle co-op (ex. ZipCar) is an
option for those who want occasional availability of a car for convenience.
14
Impor tant pearls of advice from

third year students
15
Enjoy your time now!
Be good to your fellow med students- share information and commiserate.
Your experience depends on how much effort you put into it.
Good luck. It will be a tough year.
Try to make sure you get as much sleep as you can. It is a marathon year. It is challenging
but fun in the diversity that you get to experience. If you don't know something on rounds,
in the OR, etc., look it up then or that night and it will be more likely to stick. Most people
are more than willing to help you if you are polite and respectful.
Make time for the things you love. If you're too busy to get to Whistler for a day on the
hill, get to the gym, see your life friends, take a night off with your significant other or do
whatever else it is that makes you happy this year, how on earth do you expect to fit that in
once you're in residency or once you're out in practice? Don't tell yourself you'll figure it
out later because later isn't going to be any less busy!
Try to relax and roll with the punches. You can't possibly be prepared for everything, but
you can be interested and learn a lot from asking questions.
Enjoy.
Don't be a whiner. The world has too many of those. Love the clerkship. If you want to be
a geriatric neurohematohepatopathologist you may hate obstetrics, but the 6 weeks you get
in obs will be the only dedicated time you ever get to do it. So love it. When you are in
psychiatry, work and study like you want to be a psychiatrist, when you are in surgery, you
want to be a surgeon. Catch my drift? This will ensure you get the most out of each
rotation. This also prevents boredom or burnout because you let yourself be excited each
day.
3rd year is awesome. You get to do all the cool stuff you have been wanting to do!
Third year is much more fun than expected. Don't worry if you weren't the best student in
pre-clerkship. You can definitely catch up.
Don't assume you know anything - basically, if you don't know the answer, just say you
don't know. Nothing is worse than trying to make up an answer that is clearly wrong. Not
only does it waste time, it also annoys the preceptor. Remember, they asked you that
question for a reason.
The first few months are overwhelming; it's a normal feeling. You can't bite off all of
medicine in days or weeks. Learn a small amount (especially approaches to problems rather
than the nitty gritty) by reading around your cases and you'll accrue knowledge every day.
Rural is amazing. Clerkship is way more fun and less stressful than everyone says it is, so
relax and enjoy it.
Have fun and take care of yourself! Sleep 8 hours every night you're not on call, and take at
least one full day off a week. Keep yourself happy :)
Be open to feeling foolish every day. Learning is more important than being right.
Hang in there.
Check your ego at the door. Assume nothing.
Don't stress about order of rotations. It really does work out in the end.
Take things one day at a time. If you're ever feeling overwhelmed, that is normal. Take a
deep breath, and know this feeling is not forever. If you learn one thing from each patient
you are in good shape.
Be on time! (No 5 minute grace period!) Be keen!
Have a fun-filled summer after year 2!
Don't forget to enjoy life - you know, that thing outside of medicine.
You will be alright.
16
5 things to take FULL

advantage of !
1. FREE FOOD!
There are lots of opportunities to snag free meals or beverages, such as during noon rounds,
grand rounds, morning rounds, other peoples rounds...there is no shame when it comes to the
starving medical student. Nor is there shame in going back for seconds, or taking extra food to go
after the rounds are over. With a busy 3rd year, you never know when the next chance you might
get to eat is...
2. RESIDENTS!
They will be your greatest learning resource while at work or on call. Most are amazing and
eager to teach students, and you should definitely accept any offer for education they make. Even
when walking from place to place, this poses a good opportunity to review the patient you just
saw, or come up with an approach for the next one coming up. Also definitely quiz them on their
experiences, satisfaction with their program, and any tips and tricks they might have for exams
(they did just finish them not so long ago after all...)
3. NURSES!
Do not underestimate the power of the nurse, and NEVER EVER get on a nurses bad side. They
can make your life quite difficult if they want to (luckily most dont want to because theyre so
nice). Just be collegial, treat them with respect, and ask what you dont know. They have expertise
that even doctors dont have (ie. they insert more IVs in a day than most doctors do in a month),
and are often more than happy to let you do things for your learning (ie. inserting a foley or doing
that DRE!) Also, talk to the patients nurse or read the nursing notes to get the full story of what
went on overnight.
4. ACADEMIC HALF-DAYS AND SPECIALTY/GRAND ROUNDS!

You never realize how awesome lectures are and how much you miss them until you get to third
year. These are opportunities where you finally get a chance to sit down, not stress or rush
everywhere, and actually learn without having to think excessively! Its also one of the few
chances you may have to reconnect with your fellow classmates who you might not see much of,
and actually get a chance to socialize and laugh with them.
17
5. ANY SPARE TIME!

This comes as a luxury usually, but can include time you spend walking to and from your
car/transit stop to work, time traveling across the hospital to another area, time while waiting to
review a consult with a resident/attending, or a lull in activities while on call. Use this time to
read your review book, to learn from your smartphone, to eat anything you can get your hands
on, to take a quick afternoon nap, or to hedge some sleep time early on in the call shift in case all
hell breaks loose at 2am!
18
Ten moments that will happen in

3rd year
Written by Andy Chen, MD 2013
Although everyones experiences in 3rd year will be their own and unique to everyone elses,
there are certain commonalities that every student will likely experience at some point during
their rotations, be it during the intense big 3, or in one of the smaller rotations. At some point,
these moments will occur, and hopefully this section will somewhat prepare you for it when they
do. When encountered, it isnt the end of the world, and there are always ways to adapt to such
obstacles...even if sometimes it doesnt actually look that way.
At some point...
1. YOU WILL FEEL STUPID.

This is inevitable. No matter how much you think you learned in your first 2 years of medical
school, and how many PBL patients youve diagnosed and saved, there will come a sobering
moment when you realize, ...crap Im an idiot. This isnt to say that we arent good students or
smart people, its simply a matter of fact that were still budding doctors in training, who lack the
experience and exposure necessary to understand the complexity of the human body and all its
diseases.
This event frequently happens during grilling sessions with attending, where not only is recalling
the facts hard enough, its made harder by the pressure of being in the hot seat. Avoid umms and
ahhs and truly take 10 seconds to sort through your thought processes to find an answer. If you
dont know after 15 seconds, you probably dont know at all, or wont recall it without some kind
of hint. Just admit you cant recall right now (which sounds better than I dont know), and
say youre taking a best guess (try to justify why youre guessing this way). Also cross your
fingers that your doctor doesnt love a good game of guess what Im thinking, which is nigh
impossible to win at, so dont feel too bad about it.
Take this in stride, jot down what it is that made you feel stupid, and make it a point to go home
and read up on it. Yes, the next time it comes up youll forget 95% of what you read about and
again feel like a complete dumbass, but youll once again go back and reread the topic, retain a
little more, and bit by bit we learn to become actual doctors. Until then, one can only hope that
our stupid moments dont come in front of an audience, be they attending doctor, classmate, or
patient...
19
2. YOU WILL BE SO FATIGUED AND DRAINED YOU CANT

FUNCTION.
If you thought your years of pulling all-nighters to finish term papers and cram study for exams
has prepared you well for the long hours of work for over half of the year, you underestimate the
power of the on-call shift. The specialties of internal medicine, surgery, pediatrics and obsgyn all
vie for the title of being the Sleep Deprivation Champion, meaning on average, any night where
you can get 3 hours of uninterrupted sleep counts as a blessing. Theres nothing like trying to
take a patient history while youre fighting just to try and stay awake, and at times closing your
eyes while listening to heart sounds isnt because youre trying to focus.
This means that any sleep, anywhere, should be sought. This includes on the bus/skytrain
commute, the majority of post-call days (what else are they for), and yes, even during academic
half-days (assuming youre not at the host site, itd be a little rude to snore in front of the
lecturer). When you are on call, aim for your bedtime to be as soon as theres a lull in activity
(which may be the calm before the storm), as its a complete roll of the dice regarding what kind
of night you might have.
Some residents and students do a set of tuck-in rounds, in which they go to the ward and check
in with the nurses about any concerns with any of the patients. Ideally you can avoid having a
nurse call you in the middle of the night about a patient unable to sleep because someone didnt
write a Zopiclone order on admission. It also gives you a heads-up early about any potential
problems that may arise, so if you do get called later, you have an idea about the patient and
issue, rather than trying to figure things out as you wipe the sleepiness from your eyes.
3. YOU WILL CONSIDER ANOTHER SPECIALTY DIFFERENT FROM

YOUR ORIGINAL PLAN.
Many of us go into 3rd year (or even 1st year) dead set on our future career. Everyone knows a
person in class who swears by general surgery, dermatology, plastics, etc. Whatever your
commitment level is to your specialty of choice, at some point in the year you will begin to doubt
yourself. Perhaps its during the rotation of said specialty, where you realize you dont like
6:30am rounding followed by full OR/clinic days and patient rounds until 7pm. Or it could be
after having completed another rotation you thought youd hate or not care about, just to realize
the specialtys actually quite amazing and decide youve been too hasty to judge it.
Regardless of when your identity crisis occurs, in the majority of circumstances it isnt too late to
change your plans. 4th year elective selection doesnt begin until early March, so you can always
waffle on your career plans until then. Even afterwards, theres opportunity to change your
electives (difficult, but not impossible), and in some cases, students even take 2nd clinical block
electives (post-CaRMs application deadline) in their new specialty of interest so they can justify
their applications to those residency positions should they be offered an interview by programs
they applied to. Just because you love a specialty on paper doesnt mean youre committed to it
for good, especially not until after youve experienced it first-hand.
20
4. YOU WILL MESS UP OR FORGET TO DO SOMETHING RELATED

TO PATIENT CARE.
Its often difficult enough to track everything there is to know and do for just one patient, let
alone the 4 patients youre following. Amongst all the orders, investigations, and consults to be
done, therell unfortunately be one or more instances where you forget to do something or make a
mistake in your orders. The severity of this can vary, as can the adverse outcomes, and although
hopefully both are minimal, the most important thing is to correct your error.
If youve realized it early enough to correct it without any problems (ex. wrote the wrong
medication order, but it hasnt been processed), then simply go back to change it or add an order
you forgot. If the orders been processed, but only recently, you can always write the
cancel/changed order, but make sure you let the nurse know directly as well to make sure the
original directions isnt performed.
In the cases though where youve realized or recalled the issue too late to correct, or youre asked
by your resident or attending regarding the problem, the most important thing is to own up to it.
Admit that you made a mistake, and either youre asking for instructions about how to rectify the
problem, or that youve already made the first steps towards fixing it. Although you may get
some flak for it, its far better to be honest when caught, then to be caught later on after youve
lied. Most supervising doctors are forgiving and realize that were students who are still learning
the ropes. Just be sure not to make the same mistake twice! In the end, the most important thing
is patient safety and care, with any action or mistake we make having a direct impact on their
well-being, and thus our pride and fears of getting a bad evaluation should come second to our
responsibilities as care providers.
5. YOU WILL ENCOUNTER JERKS AND BULLIES.

They may be attendings, residents, nurses, unit clerks, patients, or sometimes even classmates, but
at some point someone will be rude, mean, judgmental, inappropriate, or all of the above to
you. In all hopes, these people will be far and few between the many other encounters with very
genuine and nice people. Should you encounter a jerk or bully, however, you may find yourself in
a difficult position of which it seems the only way out is...nowhere in sight.
What you can do however, is approach the problem with a calm mind and evaluate, in order:
yourself, the situation, then the person youre dealing with. First look at yourself and ask if you
made some error or mistake that warrants the response youve received. Perhaps youre having a
bad day too and your attitude and interactions are a little less friendly than usual, and as a result
others are reciprocating what they hear from you. If thats without issue, move on to looking at
the situation. Is it currently a high-stress environment such as a critical time in the middle of an
operation or an overly busy clinic day? Is this out of keeping with the jerk/bullys usual
behaviour on other days towards you, which may point more towards them having a bad day as
opposed to their normal friendly self. Lastly if all of the above isnt true, then youre likely just
dealing with a straight-up ****.
21
Dont panic, as sometimes these people prey on fear and anxiety and simply press on to make
things worse. Instead, stay calm, act with logic and reason, and accept the fact youre in an
unfortunate position that youll have to bear through until the end of it. Simply complete your
duties to the best of your abilities, respond in a way that generates as little a conflict as possible,
and remember to take mental notes for when you fill in One45 evaluations later. However, if it
ever reaches a point where you feel attacked, unsafe, or observe actions that put patients at risk,
speak up. Contact either the site rotation director, or get in touch with the Office of Student
Affairs. Both options will provide guidance and support as to what you can do, and can also look
further into the issue with confidentiality.
6. YOU WILL CRY (OR WANT TO).

This could be for a variety of reasons. Perhaps youve had a rough day, are ready to drop dead
with fatigue, and still have 3 more patients to round on in the afternoon. Maybe you just got
pimped by your attending and completely blanked on all the questions, making a total fool of
yourself. Or, unfortunately, there are times you encounter a patient situation that brings forth
such sadness in you that tears need to be held back, such as when a patient is dying, or often
during the pediatrics rotation with very ill children.
Regardless of the occasion, its important to realize theres a time and a place for everything, and
openly crying in the moment generally isnt the best idea. Do your best to hold the tears back,
take a deep breath, and focus on the tasks that need to be done in the present. Theres also
nothing wrong with excusing yourself for a moment to gather yourself and quickly dry any tears
that might be coming forth, before going back to the work at hand.
If its been a rough day, make sure you take some time when you get home to eat, relax in
whatever way you prefer, and let out any emotions you have. Call up someone to talk to, such as
family, a friend, or a classmate, to vent, rather than pent (it all up). If you felt stupid not knowing
answers asked by your attending, remind yourself that youre only human and no one knows
everything right off the bat. Instead, think of what tripped you up, read what you dont know,
and review what you already do, so that the next time youre ready to rattle off those facts
without hesitation. And if your tear worthy moment involves a patients condition, sometimes
its ok to share a moment to cry with the patient and/or their family if youre comfortable doing
so and feel that theyve gotten familiar with you enough to accept your display of emotions. If
not, wait until you have the chance to reflect on your feelings and can find something that
comforts you when youre down (a pet is great for this), or can cheer you up (a pet is also great
for this).
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7. YOU WILL MEET SOMEONE ATTRACTIVE WHILE WORKING.

Lets face it, all of us in the health professions are a good looking bunch. At some point or other,
youll meet a doctor, resident, nurse, unit clerk that you cant help but find attractive. Regardless
of what their relationship status is, what signals you think they may be sending, or what flirting
may be going on, always keep in mind the importance of professionalism and ethics. Your career
and credibility is certainly not worth risking by making the wrong move, no matter how badly
you want to ask that other person out. As long as youre still working directly with the person,
you shouldnt make things awkward or inappropriate by making advances. And yes, although if
its the last day youll be working with someone and arent likely to get another chance to see or
work with them again in the future, therefore it feels like a good chance to test the waters, do still
keep in mind that word does get around, and gossip spreads like wildfire in the hospital setting.
So if you screw it up, it might not just be between the two of you.
8. YOU WILL BE TRIPPED UP BY A PATIENT.

This occurs when you take a great history from the patient in which you asked all the right
questions, then summarize to your attending in a perfectly paced and succinct manner. Then
when the attending comes with you to see the patient, and they ask some questions, the patient
gives completely different answers to what they told you, or brings up something that they denied
earlier on.
Oh medications, yes, I take something called warfarin. - patient (!@$&#%* but I asked you
that 10 minutes ago and you said you take no meds!) - you think to yourself, as you sheepishly
look at your attending...
I call it being trolled by a patient, and then in my imagination I feel like theyll turn to look at me
as if to say oops, sorry, u mad? Its even more frustrating if it happens more than once with the
same patient, or with more than one patient in a day. Not only do you feel embarrassed because
you look like a fool for missing key pieces of information, but you lose credibility with your staff
if it happens repeatedly.
Its best to not get too frustrated when this happens, and to keep in mind sometimes patients
genuinely do forget to mention important things, or dont mention it because to them its now the
norm or they dont find it an issue. Many a patient say no when you ask do you have high blood
pressure? because they DID but now are on anti-hypertensives and have a NORMAL blood
pressure.
Instead, take things in stride, and if your attending asks you later on why you failed to mention
something, politely explain that you did ask but the patient gave you a different answer. Never
jump the gun though and confront, or worse, argue with the patient on the spot about the issue,
as itll just make you look even worse. Hopefully most doctors will be forgiving and understand
these things happen, and just move on.
23
You can try to pre-emptively guard against this situation from arising by asking patients questions
in a specific way, such as providing a multitude of examples to jog their memory. Rather than
do you have any medical conditions?, try do you have any medical conditions, such as high
blood pressure, high cholesterol, diabetes, lung, liver or kidney disease, or a past history of heart
attacks, stroke, blood clots, or cancers? Its a mouthful, but if you get in the habit of asking it in
this way you can save yourself quite a few pitfalls hopefully. The same goes for when youre
presenting to an attending or resident. State that the patient denies having hypertension, lung
disease, diabetes, past histories of... (tailor it so you list 3-4 of the key negatives, then end with
or any other medical conditions). At least this way if it still happens where the patient goes oh
yeah, I did have cancer years ago and you feel like banging your head against a wall or crawling
under the patient bed, you know youve already done everything you could to safeguard against
this event.
9. YOU WILL WANT TO GIVE UP.

It may come within the first month of clerkship, or you could hold out until the end of the year.
Typically it happens some time during the big 3, probably after a brutal call shift. Youll
question why youre even here, why you even bother, and why everything seems so hard or if
youre just not cut out for this. Then you wonder perhaps its better if you quit before you
actually fail, and then one thing leads to another and before you know it youve worked yourself
into a frenzy of anxiety and fear about the possibility of flunking med school, and just wanna
give up and become a low-level employee in a fastfoodrestaurantoraclothing storeinstead
*GASP!*
Stop. Breathe. Remember what got you here so far. If they made a mistake and let you into med
school by accident, they wouldve figured that out by now, and if youre as dumb as you feel you
are, you wouldve flunked out already. Neither of those facts are true, so that means you deserve
to be where you are and youll most certainly make it through. Organize your schedule to sort
out your work, study, and personal time, make it a goal to learn 3 new facts a day at the very
least, and rely on your family and social supports for some reassurance, encouragement, and
relaxation. Put the thought of giving up out of your mind, since that option isn't even on the
table because it doesnt need to be. Everyone will make it through.
10. YOU WILL FEEL PROUD OF YOURSELF AND YOUR WORK.

In between all the above moments of pressure, frustration, anxiety, fear, and confusion, there will
come a time when you do something right. Something that makes you feel smart, pleasantly
surprised, proud, and start to make you realize that perhaps you are cut out for this, and that
youre on the way to becoming a good doctor. Then that moment will happen again, and again,
and continue on with increasing frequency throughout the year. Congratulations, youre learning
to be a doctor.
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Its all too easy to forget that those amazing genius doctors and residents we look up to have at
the very least, 2 extra years (if not 20) of experience and learning on us. They most certainly
didnt know everything they do now when they were at our stage, and even despite some of their
expectations (which can be unrealistic), we cant know everything they know now. Medicines a
multi-step process, and the learning curve will be revisited over and over again, but with each
repetition, the curve will be less steep and shorter in length.
When you actually end up doing something right or knowing the answer to something hard, feel
proud. Remember these moments, and come back to them when youre feeling inadequate and
questioning yourself. Dont forget that even if sometimes your effort feels unrecognized or
unappreciated, you have made some kind of difference in the lives of your patients, and that this
is what your future will hold. We might not be doctors quite yet, but were certainly on our way
there with each of these moments.
25
DOCUMENTATION
Edited by Lawrence Haiducu, MD 2014
How to write consults, orders, notes and dictations ............... 27

I. Star t/end of anything written and general tips .................. 28
II. Consultations and dictations ......................................... 29
III. Admission orders....................................................... 36
IV. Daily progress notes and orders .................................... 39
V. Discharge dictations and summaries ................................ 40
VI. Procedure notes and orders.......................................... 42
VII. Specialty specific aspects/components .......................... 43
26
The CLERKSHIP GUIDE | Documentation
How to write consults, orders,

notes and dictations
Documentation is a crucial aspect of medicine and, as medical students, it is our responsibility to
learn how to write appropriate consultations, orders, and notes. Not only is it a communication
tool to relate information to other healthcare staff involved with the care of the patient in the
present and future, but it also plays a potential role in legal issues, and thus should be taken
seriously.
Documentation should be succinct, relevant, and of course, legible! Doctors have been plagued
with a type of acquired dysgraphia that presents at variable periods later on in our careers, but the
most effective prophylaxis is developing good writing habits early on. This means writing on the
lines, picking up your pen off the page in between every word at the very least (if not between
every letter), avoiding obscure abbreviations/acronyms, and rewriting anything you think might
not be readable. Not only will colleagues appreciate you for this, but its in the name of patient
safety. Although not all of us were blessed with advanced calligraphy skills, even the worst of us
can make our chicken-scratch lettering legible with minimal effort.
Lastly, every specialty has a particular style and preference for their documentation, as well as
possibly containing unique focuses or components. Internal medicine progress notes requires a
well detailed differential diagnosis and management plan, surgerys focus is on common post-op
complications (ex. fever), and pediatrics always want to know fluids in/outs and weight changes.
Become familiar with both what the specialty looks for, and what your attending and residents
prefer, and tailor your writing to those expectations initially, until with time, you become
comfortable having developed your own methodology and style!
27
I. Star t/end of anything written

and general tips
Regardless of what youre writing, it should always have some common components:
1. Every consult, note or order should identify somewhere near the top or at the start, what
service is involved (ex. internal medicine), who is writing (ex. MSI 3), and what is being written
(ex. progress note). It also helps to underline this, which helps for quick reference as to what the
note is, and to be able to find previous notes easier.
Other examples: Surgery MSI3 - POD #1 progress note (POD=post-operative day),
Pediatrics MSI3 on call - overnight note, Internal medicine MSI3 - addendum note.
2. The date and time of writing should be on the top left side of the note or at the top of the
consult. Write this out as month day, year (ie. Apr 1st, 2012), in order to avoid confusion. The
time of writing should also be documented in 24hr time (ex. 1600h, not 4:00), which may require
practice before it becomes intuitive. This is again to avoid potential confusion with AM/PM (or
forgetting to write them).
If you stop your note halfway to do something else, then come back to it a while later, you should
update the time of the 2nd half to avoid confusion regarding timing (ex. having lab results on a
morning note from orders you wrote in the afternoon). Alternatively, you can start a new note
titled addendum.
3. Anything you write should be completed with your signature, your name printed, level of
training (ex. MSI3), your pager number, and if it was discussed/reviewed with an attending or
resident (required for most physician orders). For example, a note may be ended with a signature
and Andy Chen, MSI3, 604.450.2385, d/w Dr. House. If it was reviewed with a resident,
identify their year of training (ex. R3) after their name.
4. If you ever make a mistake in writing, cross it out with a single horizontal line, then write
error and initial beside or above it to verify that a mistake was made. Continue on writing next
to the error. If you ever need to insert extra words or phrases retrospectively, initial those too.
5. Refer to yourself as writer (ex. patients nurse told writer). If you use names for other
people, put their position in brackets (ex. writer discussed with Jane (RN)).
6. Avoid making up abbreviations or using uncommon ones. If in doubt, write it out!
7. When writing orders, only 1 order per line! For example, each medication being ordered
should be on its own line, not chained together in a continuous sentence.
28
II. Consultations and dictations

Most patient cases begin with a consultation in emergency, regardless of what service youre on.
As usually youll be the first medical personnel to have time for a full assessment of a patient and
their problems, a complete history should be taken. Each rotation/specialty will have a
preference for what to focus on, as well as unique parts to a complete history, but all of them
should have the following common elements:
Patient identification and reason for referral/chief complaint
Histor y of presenting illness
Past medical/surgical histor y and review of systems
Medications
Allergies
Social histor y
Family histor y
Physical Examination
Investigations and labwork
Impression
Differential diagnosis
Plan
1. PATIENT IDENTIFICATION AND REASON FOR REFERRAL/CHIEF

COMPLAINT:
This should be a sentence stating who the patient is, relevant medical conditions, and why they
were referred to the service or why they came in to the hospital.
Ex. Mr. Ed Issine is a 54 year old Caucasian male with a 5 year history of hypertension and
recently diagnosed diabetes type 2 presenting to ED with complaints of chest pain that started an
hour ago lasting for 10 minutes, which was relieved with rest.
29
2. HISTORY OF PRESENTING ILLNESS:

This section details the events leading up to their current condition, including any pre-existing
associated medical conditions. Although initially the timeframe is dictated by the patient (ex.
they state their problem started that morning when they felt a dull pain in their chest), the prior
history should be explored to elicit any other relevant details (ex. theyve actually had high blood
pressure for the last 5 years). It should also include the events that have occurred since they were
brought to hospital (ex. the ED physician has seen the patient, administered nitroglycerin x 1
spray, and ordered CBC/electrolytes/troponin). For taking the history, one can use the
LMNOPQRSTUV structure (or any other mnemonic preferred):
Location: Where is the pain or complaint? May not be one specific/localized area.
Management/medications: Whats been done about it? Whats been taken?
New/old: Is this the first time this has occurred, or is it a chronic problem?
Onset: When did it start? Is it still ongoing?
Precipitating/relieving factors: What makes it better? What makes it worse?
Quality: Whats the pain like? Is it sharp, dull, throbbing, aching, burning, etc?
Radiating: Does the pain spread anywhere else? Do you have shooting pains?
Severity: How bad is the pain on a scale of 1 to 10 (1=no pain, 10=excruciating)?
Timing: Does it come and go, or is it constant? Is it better/worse at a certain time of day?
Unusual features: Is there anything else odd or unexplained that youve noticed?
Various conditions: Are there any medical conditions you have that are related?
3. PAST MEDICAL/SURGICAL HISTORY AND REVIEW OF SYSTEMS

Inquire about any other medical conditions the patient has, when they were first diagnosed,
whats been/being done about them (ex. meds, doctor following this), and if its causing them
any problems right now. Surgeries should have a date of occurrence, a hospital location, the
reason why, and if there were any complications during or afterwards. A brief review of systems
should be performed here to elicit any other medical conditions the patient may have forgotten or
are undiagnosed. Frequently patients may say no Im pretty healthy, until you ask them if they
have high blood pressure, diabetes, or high cholesterol, which jogs their memory and they state
oh yeah, that. Write down negatives to indicate you did actually inquire about them (ex. no
symptom history of COPD, CHF, GI issues, infections, etc...)
4. MEDICATIONS
A complete list of medications the patient is currently taking should be compiled, including the
dosages, route, and frequency. Further information should be gathered regarding how long
theyve been on the medication, what its for, if its been effective for them, and if there have been
any side effects or adverse reactions. Many patients may not remember the names of their
medications, but know its for the heart, or for asthma, and thus may require some memory
jogging from the student.
30
One can also refer to the Pharmanet report for the patients recently filled prescriptions, but dont
rely on this completely as some medications patients may fill but not take, and some medications
patients may take but arent on Pharmanet (ex. GP office samples). Its best to go through the list
with the patient and ask if theyre still taking each medication. If they stopped taking any
particular medication, ask why.
Also, dont forget to inquire about naturopathic/herbal medications, over-the-counters, and illicit
medications (ask specifically marijuana, cocaine, heroin, crack, or other illegal drugs, as not all
patients consider certain medications illicit).
5. ALLERGIES
Inquire regarding any food, drug, or other allergies, and if there are any, ask specifically how they
know theyre allergic to this, and what exactly happens when the patient is exposed to this. This
needs to be differentiated because often patients become mixed up between a true allergic
reaction (ex. anaphylaxis, rash), a food/drug intolerance (ex. nausea, diarrhea), and whats
simply a drug side effect (ex. drowsiness, malaise). Also ask what resolves the allergy, and how
long it usually takes.
6. SOCIAL HISTORY
This section is concerned with the patients personal background, living situation, available
supports, and other social factors that may play a role in their health. Keep in mind that the time
available for the histories is limited, and often much of social history will need to be postponed
until after admission. Only ask what you think could be relevant, but also feel free to use many
of these questions as rapport building tools to get to know your patient better and show youre
interested in who they are, not just what medical condition they might have! Personal
background information can include:
Question
Where were they bor n and where
did they g row up?
Relevance
Cultural background and child developmental situation
can play a role in their beliefs on health and actual
health
What their religion/cultural beliefs May affect their decisions for acceptable medical
are?
treatment (ex. Jehovahs witness, no blood transfusions)
What level of education did they Affects their general social functioning, ability to
achieve?
understand your use of medical language and care plan
What job do they currently have or Occupational hazards (ex. lead exposure) may be
had held?
relevant, and also provides info regarding current
financial situation
What hobbies do they have?
Other exposures/risks (ex. pigeon-keeping, mushroom
farming)
Whats their current marital
Spouses/partners and children can provide collateral
status? Any children?
information, or may be a source of stress or harm (ie.
abuse)
31
Their living situation relates to where they live, what kind of place they live in (ex. house, condo),
do they own or rent, who lives with them, do they feel safe at home?
Available supports can include family, friends, mentors, educators, or advocates. Do they feel like
theres someone who can help them in times of need or ill health?
Other social factors include stressors, dangers or risks to their health, financial strain, recent
significant life events or trauma, and any other worries or concerns.
Specific inquiry must be made into their smoking and drinking habits. If they say they dont
smoke, do they mean now, or ever in their life? If they say they do/did smoke, how much? How
long? How frequently? Have they planned/attempted to quit before? How do they feel it affects
their health?
In regards to alcohol use, how many drinks per night/week? What happens after theyve drunk?
How do they feel about their drinking? Have there been any adverse effects (ex.cirrhosis, social
dysfunction, etc). If necessary, a CAGE screen (cut down, annoyed others, guilty about, eyeopener use) can be used, time permitting on an appropriate candidate where alcohol abuse may
be suspected.
In either the case of smoking or drinking, one should initially grossly overestimate the amount
that someone may smoke/drink. If the student suggests smoking 3-4 packs a day or having
10-15 alcoholic drinks a night, it encourages the patient to admit to their actual amount, which
is usually less than this extreme by comparison, in the patients mind, and additionally assesses
their idea of normal amounts (ex. one patient encountered considered an entire bottle of
whisky as being not that much!).
7. FAMILY HISTORY
A family pedigree should be drawn to demonstrate first degree relatives with their corresponding
ages. Any history of the presenting condition among other family members should be explored,
including if they were formally diagnosed, how they were managed and what the
current/planned treatment is for those individuals? Are there any other inheritable conditions
(ex. Huntingtons) or illnesses that have a familial component (ex. diabetes,
hypercholesterolemia)?
It is not sufficient to ask is there any family history of illnesses? as many patients wont have
good spontaneous recall of family conditions. Instead, make suggestions of common illnesses
such as high blood pressure or cholesterol, diabetes, heart or lung disease, cancers, liver or kidney
problems, major surgeries, and any common types of disease related to the patients likely
diagnosis.
32
If any positives turn up, ask regarding how old were they when they were diagnosed, what age
they are now or at what age did they pass away, what kind of treatment/management was done,
how effective this was, and what their current status is. This may be time consuming if ones
common sense is not used to decide what is or isnt relevant to the patients current situation (ie.
dont need to explore an uncles history of eczema if the patients current complaint is pain with
urination).
8. PHYSICAL EXAMINATION
A focused physical exam should be performed on the organ system suspected to be the leading
diagnosis, and screening exams should be performed on the other systems. Every patient case
should have vitals taken/noted (see figure below for shorthand form), and depending on the
length of time elapsed, may have both the vitals on triage and vitals now jotted down (as any
change can be relevant).
The major systems to examine and the basic questions are listed below:
Head and neck (H+N): Pupils equal and reactive to light and accommodates (PERLA)?
Extraocular movements intact (EOMI)? Tympanic membranes and oropharynx normal?
Neck supple? No lymphadenopathy? Thyroid normal?
Cardiovascular (CVS): Pulse rate, amplitude and rhythm normal in 4 limbs? JVP normal
height and characteristics? Heart sounds normal in 4 areas? Any murmurs, thrills, heaves,
or arrhythmias? Any peripheral edema?
Respiratory (RESP): Breathing rate normal and regular? Good bilateral air entry
(GBLAE)? Any crackles, rubs, or wheezes? Any pain or dullness on palpation/percussion?
Any abnormal rib cage or diaphragmatic movements?
Gastrointestinal (GI/ABDO): Distended or scaphoid? Intestinal sounds normal? Pain or

masses on light/deep palpation of quadrants? Rebound, guarding, or ascites? Mcburneys
point tenderness (for appendicitis)? Liver span or gallbladder tenderness (Murphys)?
Splenomegaly? Hernias?
Genitourinary (GU): Costovertebral angle (CVA) tenderness? Kidney palpation normal?

External genital exam or pelvic exam normal (only done if problem suspected)?
Musculoskeletal and neurological (MSK/NS): Limb bulk, strength, tone, and reflexes
normal? Dermatomal sensation and proprioception normal? Gait, coordination, and other
nervous system signs normal? Any dermatological concerns (ex. rash, ulcer, vesicles, etc.)
or physical injuries (ex. lacerations, bruises, dislocations) to be noted?
9. INVESTIGATIONS AND LABWORK

Often patients will already have had some investigations ordered and possibly performed after the
initial emergency physician assessment already. This is typically bloodwork (ex. CBCD,
electrolytes, BUN, Cr), and may also include a chest x-ray (CXR), ECG, urine dip, or urine tox
screen. Document these results on the consult form as well.
33
10. IMPRESSION
This is a statement summarizing all the information available thus far, and should include what
one believes the most likely diagnosis is (or if it cant be differentiated at the moment), and why
this is or what this conclusion is based on.
Ex. Mr. Ed Issine is a 54 year old Caucasian male with a 5 year history of hypertension who
presented to ED with complaints of chest pain that occurred an hour ago while he was
gardening, and lasted for roughly 10 minutes. He describes that it was an uncomfortable pressure
on his chest that was constant, with some of the same sensation occurring down his left arm. He
also had some shortness of breath and diaphoresis during that time. The pain went away after he
sat down and rested for a while. An ECG and bloodwork including troponins has been ordered
and is pending. Given the clinical info, the most worrying diagnosis is acute MI, and will be
managed as such while other possible differential diagnoses are ruled out concurrently.
11. DIFFERENTIAL DIAGNOSIS

This section is where you consider all possible conditions that fit the patients clinical picture, and
describe what evidence may or may not support each differential. What further investigations that
will/should be done that could help to rule in or out specific diagnoses should also be noted here.
Order the differential from most likely to least likely, but dont be afraid to cast a wide net using a
systems-based approach or VINDICATE as a brainstorming aid. Although many of the
conditions you come up with may be clearly unlikely to be the case, your attending still
appreciates knowing you had considered this at the very least, and that you understand why its
being ruled out.
12. PLAN
It is here that you provide a clearly delineated list of actions that are planned for the patient,
which should include the immediate care plan (ex. admit vs discharge +/- follow-up in
community), and may include both actual orders for investigations and medications, general
medical care (ex. will monitor hourly vitals for change in stability), or non-medical actions (ex.
will liase with social worker to arrange for community housing). If there is a foreseeable course
in hospital, one can comment too on when expected date of discharge may be (ex. patient to
stay for 3-4 days until UTI-induced delirium resolves, then can be d/cd home with follow-up
with family doctor).
Once complete, all consults should be reviewed with a resident (if available) and attending to
discuss the plan and make any adjustments. In practicality, at the 3rd year level its unlikely for us
to create the perfect correct care plan. Its best to write up to the differential diagnoses, then
discuss with the supervising resident/attending regarding the plan before you write it down.
However, before reviewing, you should formulate in your head a patient care plan and why, as
this is when staff will likely quiz you.
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Depending on the service, there may be a requirement that all consults are dictated into the
system, even if the consult sheet has been written out. Consultation dictations generally follow
the written format demonstrated above in the exact same fashion, but are more fluid as complete
sentences are spoken. Access to the dictation system varies from hospital to hospital, so check
with the unit clerk or supervising doctor for instructions. Youll also need the dictation code of
the attending staff doctor (unless youve been assigned your own code). Begin every dictation
with:
This is (name), (3rd/4th) year MSI, dictating on behalf of (attendings name). This is a
(dictation type, ie. consultation note) on patient (name, then spell it out), patient ID # (read it
out). Please send copies to Dr.(names of attending, referring doc, and pts GP)
Memorable Moments
"Whilst on my rural rotation my joke-loving preceptor told me to go examine a
19 year old female whose mother had ""diagnosed"" her with pneumonia and
sent her to the emergency room. After conducting a thorough examination I
returned to my preceptor and stated, ""if she had pneumonia I'll eat a fluorescent
light bulb"".
""One of those great long ones?"" he asked to which I affirmed.
We went back to the patient and my preceptor pointed at me, looked at the
patient and said, ""he says, if you have pneumonia, he will eat a fluorescent light
bulb.""
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III. Admission orders

Once the consult has been completed, orders will need to be written. As with the care plan,
students should think ahead on the orders they believe will be needed, then discuss with the
supervising staff and work through the orders together. Admission orders can be summarized as
follows (using the ADCADAVID mnemonic):
A: Admit to Dr. ___, (specialty). Who the attending is, and their service.
D: Diagnosis. The leading diagnosis at the moment, or the main symptom followed by NYD if
not yet diagnosed.
C: Code status. Generally full code, but some senior patients may have a DNR order or other
advanced directives in place.
A: Allergies. What drug, food, or other allergies are there, and what happens if they are exposed
to this?
D: Diet. What can/cant they eat, and in what timeframe? Ex. diabetic diet, NPO (nil per os),
fluids only; after midnight, until no nausea, etc.
A: Activity. What can/cant they do, and in what timeframe? Ex. AAT (activity as tolerated),
bedrest, progress to weight-bearing as tolerated, etc
V: Vitals. How frequently should vitals be taken? Ex. vitals regular (note that this could vary
between different services, ranging from once per day, once per shift, or once per 4 hours),
q30min, qshift
I: Investigations/IV. Any tests to be ordered, such as bloodwork, x-rays or other imaging,
urinalysis, etc. Note that for bloodwork, some things need to be specifically named out (ex. liver
tests isnt acceptable, as it should actually be written out as AST, ALT, ALP, GGT, albumin,
bili). IV solutions should also be ordered at a specified infusion rate for either replacement or
maintenance fluids (ex. NS w/ 40mEq KCl/L at 100mL/hr).
D: Drugs/Directions. Drugs that need to be ordered include those that were using to treat the
patients condition, drugs that the patients are taking normally, and drugs that are useful for while
staying in hospital. In general, students should become familiar with the popular and frequently
used medications for when patients are to be admitted. To consider possible needs for
medications, one can use the 6 Ps. Some common options are also demonstrated:
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1. pain (analgesics)
-review opiates with
residents/staff! They all have
their own preferences!
Tylenol 325-650mg PO/PR q4-6h PRN (max. 4000mg/day)

morphine 5-10mg oral liquid q4h PRN (hold if RR<10)
hydromorphone 1-2mg PO/SC q4h PRN (hold if RR<10)
2. pus (antibiotics)
far too many choices to list, but consider it in terms of

coverage for gram+, gram-, anaerobes, and atypicals
3. pillow (sleep)
zopliclone 3.75-7.5mg PO qHS PRN
4. puke (nausea)
Gravol 25-50mg PO/SC/IV q6h PRN

metoclopramide 5-10mg PO/IV q6h PRN
ondansetron 4-8mg IV q8h PRN
5. poop (constipation)
bowel care protocol (most hospitals have their own in

place)
lactulose 30-45mL PO (titrate dose freq. for 2-3 BMs/day)
6. personal meds
any medications previously being taken should be reordered

or patient can take own (this still requires an order to be
written out). Pharmanet reports can be helpful. Also
remember to HOLD any medications you dont want the
patient to take.
7th non-med P is pee - consider whether the patient needs a foley (avoid if possible)
Some general rules/tips:
37
Dont forget that orders are written one per line only!
Every med order requires the name (generic), dosage, route (ie. PO, IM, etc.), and the
frequency (ie. daily, BID, qHS, etc.). Also set limits to the maximum daily doses if needed
(ie. max. 4000mg/day of all acetaminophen containing products)
Follow good prescribing practices! This means not using ug for micrograms, no
unnecessary trailing 0s, add leading 0s before the decimal, and avoiding easily misread
abbreviations such as OD or QD (write these out as once daily).
Dont forget to flag the orders on the chart (or wherever the unit wants orders to be flagged)
after you write them, or they might be missed! Flagging orders means either pulling up a
sliding flag in the chart that says "Doctor's Orders", or raising/putting up a flag or marker
at the location where the chart is kept.
For any stat/urgent orders, or complicated instructions, talk directly to the nurse first,
then to the unit clerk, to ensure the orders are completed quickly and accurately.
Even though it is up to the writer to contact specific services for a consult (ex. Addictions
medicine), or to help the patient (ex. physiotherapy), these still benefit from a written order
(ex. addictions med to see re: substance use), as then the unit clerk can add the patient to
that services rounding lists as a reminder for that team to see the patient.
Dont forget to fill out any additional forms that may be required! X-rays and other imaging
usually requires a Radiology requisition form to be filled, certain medications may have a
protocol form (ex. heparin), etc. The need for certain forms vary from hospital to hospital,
so its best to ask the unit clerk when unsure.
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IV. Daily progress notes and

orders
Daily progress notes should begin with a brief identifying info statement, followed by a note in
the SOAP format (Subjective, Objective, Assessment, Plan). The ID statement helps as a quick
reference for future readers as to who the patient is, their reason for admission, and their status up
to now.
Ex. Pt is a 54 y.o. male admitted 2 days ago for chest pain diagnosed as angina, with acute MI
ruled out. Hes currently stable and has been started on aspirin and metoprolol. A stress test is
ordered and is expected to be completed today.
The SOAP note documents the patients current status, and outlines the upcoming plan. Every
patient the student is responsible for requires a daily evaluation and SOAP note to be completed
in the course of rounding. Abbreviated SOAP note updates/addendums can be written as plans
are reviewed with supervising staff or residents, or as certain tasks are completed.
Ex.Update: reviewed patient with occupational therapist and dietitian regarding lifestyle changes
for lowering BP and cholesterol. They will see patient today.
Any orders to be done can be written as a numbered list on the physician orders sheet, signed
noting who its been discussed with, and then flagged as a new order. As mentioned above,
flagging orders means either pulling up a sliding flag in the chart that says "Doctor's Orders", or
raising/putting up a flag or marker at the location where the chart is kept. As noted, for any
stat/urgent orders, or complicated instructions, talk directly to the nurse first, then to the unit
clerk, to ensure the orders are completed quickly and accurately. Depending on the hospital or
rotation, orders may require a co-signature for all orders by staff or a resident (ex. pediatrics),
while other services may not care if med student orders are co-signed as long as it notes who it
was discussed with (ex. Psychiatry).
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V. Discharge dictations and

summaries
When a patient is discharged, a dictation should be completed to document the course of the
patients diagnosis and treatment in hospital, as well as to share this information with the
professionals involved in follow-up care. Although many similar elements of the initial
consultation dictation are shared, they are rearranged into a different format as follows (note that
this can vary depending on the hospital site and attending preference for discharge dictations, so
ask when in doubt):
Patient identifying information and reason for admission
Most responsible diagnosis
Pre-admission diagnoses (ie. medical history)
Post-admission diagnoses (ie. any other diagnoses made in hospital in addition to the
most responsible diagnosis,ex. C.diff infection)
Code status
Operative interventions (eg. intubation, central lines)
Names of relevant specialists (list your attending here with the name of their service, along
with any other specialists that were consulted during the patients stay in hospital, eg. Dr.
House, nephrology)
Allergies
Medications on discharge
Post-discharge follow-up (ie. whats the plan after discharge?)
Discharge disposition (i.e. where they have been discharged to. For most patients, this will
just be home, but it could be a nursing home, a family members care, etc.)
Treatment/course in hospital (this is where you give a short narrative about what happened
while the patient was in hospital)
When you are dictating, you need to state exactly what you want to have written on the final
paper summary. So, for example, after stating your name and the proper introduction as outlined
earlier, you would say: New paragraph heading. Most responsible diagnosis. Colon. New Line.
COPD exacerbation. New paragraph heading. Pre-admission diagnoses. Colon. New line. In list
form please. One, non-insulin dependent diabetes. Two, hypothyroid. Three, left breast cancer
with mastectomy in 2009. New paragraph heading... and so on, which will come out on paper
looking like this:
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Most responsible diagnosis:

COPD exacerbation
Pre-Admission Diagnoses:
1) Non-insulin dependent diabetes
2) Hypothyroid
3) Left breast cancer with mastectomy in 2009
Etc...
Dictating can be a bit unpleasant and difficult to get used to, so get a resident to walk you through
it the first time. If you can, listen to someone else do a dictation before you attempt one.
41
VI. Procedure notes and orders

Following any procedure (surgical or otherwise), a note should be written to document the
operation/procedure and findings, as well as a set of orders for when the patient is admitted to
the wards (or new management requirements post-procedure). Both these types of
documentation provide a good opportunity for students to be involved more in patient care, help
out the resident, and learn more about management. Procedure notes may vary, but the general
surgical OR note has the following:
Surgeon: who the primary surgeon(s) was/were, and what specialty they were?
Assists: who the assisting staff were (ex. residents, MSIs, GP assists)?
Anesthesia: who the anesthetist was (look on the OR board or ask the nurses if you havent
caught the name already during the OR)?
Procedure: what surgery was done (hopefully you listened, but can also look on the OR
slate sheet), and using what method (ex. laparoscopic, open, etc)?
Pre-op diagnosis: what was the preliminary diagnosis pre-surgery?
Post-op diagnosis: whats the diagnosis after the surgery, which may not always be the same
as pre-op, depending on findings.
Findings: what was observed/found in the OR, and were there any samples taken and sent
to the pathology lab (or other departments)?
Complications: were there any unexpected events or findings during the procedure, and
what was done in regards to this?
Estimated blood loss: whats the best guess at the amount of blood the patient lost? Look at
the suction canisters to guesstimate, but remember to account for any other fluids such as
saline rinses. If the amount was relatively minimal, <50mL is a reasonable EBL. If youre
writing anything greater than the 300-400mL range, definitely discuss with your resident or
attending first!
Disposition: how was the patient when he/she left the OR, and whats the plan for them
after? Stable, awake, moving? How long is it expected for the patient to be in the postanesthetic recovery room?
Often pre-printed post-operative order sets are available to be filled in. They structuralize aspects
of post-surgical care and list a number of commonly used medications (ex. heparin, analgesics,
anti-nauseants) that can have its box ticked off as needed. Although they can appear complicated,
theyre relatively straightforward, but certainly work with the staff or resident to go through these
order sets. If orders are handwritten, consider it like doing a full set of admission orders again
with ADCADAVID, in which all their pre-operative medications need to be re-written, along
with any new medications they should receive.
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VII. Specialty specific

aspects/components
Certain specialties have additional focused sections of a complete history that is unique to their
field, and thus these components should be adjusted as appropriate.
OBSTETRICS
In obstetrics, there is more than one patient to be concerned with during the interview. Questions
need to be asked regarding both the womans health and current condition, as well as that of the
babys. Any consult or history on a pregnant patient must include key information such as the
gestational age of the baby and if any complications have arisen so far? In the acute setting when
a mother presents to the hospital stating theyre in labour, one can quickly determine the urgency
with 4 key pieces of information:
Contractions: When did they start? How strong/painful are they from 1 to 10? How far
apart are the contractions? Are they becoming stronger?
Membranes: Have you felt a gush of fluid/leaking/dampness in your underwear? Has your
water broken (if its not her first pregnancy)? What colour was it?
Bleeding: Has there been any blood or spotting on your underwear? How much is it if there
is? What colour was it? Was it liquid or clots?
Fetal movements: Is baby still moving the same amount as youre use to? If its less, how
much less or how long between movements?
On top of the normal history components, it is also important to obtain a thorough obstetrics and
gynecological history for any presenting patient, which includes the following information:
Obstetrical History:
How many weeks pregnant are you? Is this based on LMP or a dating ultrasound? Did the
ultrasound show anything abnormal? How has the pregnancy been thus far? Any complications
or problems, such as spotting/bleeding (how much/when), or major illness/hospitalization (what
and treatment received)? What exams or screening has been done already? Blood tests? Group B
Strep and other STI screen? Any concerns like high blood pressure (gestational hypertension) or
blood/urine sugar (gestational diabetes)? Is this your first pregnancy (GTPAL)? How were the
previous pregnancies and deliveries (method and term)? When and where were they? Any
complications? Was instrumentation (ex. forceps or vacuum) or a c-section required, and why
43
Gynecological History (not all questions are appropriate! Tailor to the patient):
When was your LMP, and what was the character of it? Whats your normal menstrual cycle like,
both on and off OCP? How long is your cycle, and how regular is it? How many days is the
menstruation? Would you describe your flow as heavy or light? How many pads/tampons do you
need to change in a typical day of menstruation? Any cramping or pain with menstruation? Any
PMS symptoms? If post-menopausal, when did your period stop, and has it been consistently
gone? Any associated symptoms such as hot flashes or irritability? Any hormone replacement
therapy (HRT) being taken? Any cancers?
Are you currently sexually active? Is it a steady partner, or multiple partners? If a steady partner,
how long, is the relationship doing well, and are there any concerns of infidelity regarding your
partner? How many partners have you had in the last 6 months? Do you have sex with men,
women, or both? Any pain during sex? Do you feel safe, or have you ever felt threatened or
harmed in sexual encounters?
Are you currently using any form of birth control? If OCP, which one, when did you start taking
it, how has it been, any side effects, do you ever forget to take pills, and what do you do if that
happens? If IUD, which one, when was it inserted, how has it been for you, and do you still use
barrier protection? If barrier protection or other method, how consistently is it done, and how do
you feel about it?
Any history of STI? Which one, and what was done about it? Did any complications result from
that episode or currently? Was it reported and the source traced back?
Any previous surgeries of a gynecological nature? What and when? Any complications resulting
from them? How do you feel now about it?
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PSYCHIATRY
In general, psychiatry patients have already been medically cleared by the emergency doctor, or
have a hospitalist/GP overseeing their general health while they are an inpatient. As such, many
psychiatric consultations do not require a full physical exam, and instead can be summarized
with the last vitals taken, then stating that theyre stable and have been medically cleared already.
Instead, the physical exam should be replaced with the mental status exam (MSE), the
observational equivalent of the physical exam for the mind. The MSE is summarized by the
mnemonic IAMSEPTIC:
I
Identifying info
Appearance of the patient
Patients actual age, apparent age, ethnicity

Physical appearance, including notable features (ex. facial hair,
A
scars, etc) and body habitus. Hygiene and appearance of
health. Clothing worn, style, cleanliness, appropriateness.
Mannerisms and motorisms Body language and position (ex. relaxed, tensed, slouched,
etc). Use of hand gestures or other body motions.
M
Psychomotor agitation/retardation. Abnormal movement
patterns (ex. posturing, chorea, tremor, etc).
Speech usage and patterns Speech rate, rhythm, prosody, tone, volume, amount, range,
S
spontaneity, coherent/non-sensical. Neologisms, swearing,
rhyming, clang associations, vocalizations, mistaken word use.
Emotional affect and mood Affective state (ex. euthymic, happy, sad, angry, anxious, etc).
state
Affect stability/lability, range, and congruency to mood. Mood
E
as stated by patient or inferred from interview/thought
content.
Perceptions
Hallucinations (ex. auditory, visual, tactile, olfactory,
P
gustatory), illusions, depersonalization, derealization.
Thought content and
Process organized and logical, goal-directed, circumstantial,
process
tangential, loose associations (+ pressured speech = flight of
ideas), word salad, illogical, disorganized and illogical.
T
Content may include delusions/ideas (ex. grandiose,
persecutory, paranoid, etc), obsessions, magical thinking, ideas
of reference, suicidal ideation, homicidal ideation.
Insight, reliability, and
Insight intact/full, moderate/partial, mild/limited, none.
Reliability of patient as historian and other major events.
I judgement
Judgement good, moderate, poor, none.
Cognition and memory
C status
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Cognitively intact/alert/oriented, disoriented, delirious, any

dementia present, and memory function like this. General
assessment of patients intelligence and overall status.
Patient assessments require a multi-axial diagnosis, unique to psychiatry:

Axis I: any psychiatric disorder, including substance induced conditions, but excluding axis II
diagnoses
Axis II: personality disorders and mental retardation deficits
Axis III: general medical conditions (not directly affecting/causing axis I diagnoses)
Axis IV: social/environmental factors, that affect or are related to the psychiatric diagnoses,
including stressors/barriers to treatment/recovery
Axis V: global assessment of function (GAF) score, ranging from 0-100. Refer to other resources
for the breakdown of score ranges. In general, any score less than 40-50 requires admission for
hospital management
The biopsychosocial model of patient management consists of:

Bio: psychiatric medications or treatments that will improve the patient condition, such as antidepressants, anti-psychotics, anxiolytics, or electroconvulsive therapy
Psycho: psychoeducation (teaching the patient and family about the diagnosed condition and
management expectations), psychotherapy (ex. cognitive behavioural therapy), outpatient
psychiatrist and mental health team care
Social: assessing and alleviating stressors (ex. family situations), social worker assessment,
housing and safety, financial management, occupational issues, drug rehabilitation, caregiver
fatigue management
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AMPLE HISTORY (EMERGENCY)

There are situations in which a comprehensive history is either not practical or necessary, either
limited by time or situational constraints. For example, a critical patient coming into emergency
that requires urgent surgery. In place of a full history that can be taken later, an AMPLE history
may be done instead. The acronym covers pertinent information for patients that require
emergent care, and stands for:
A: Allergies
To prevent administering drugs that could have adverse reactions
M: Medications
To consider drug interactions, and as collateral for PMH
P: Past med Hx
To determine general health and stability for procedures
L: Last meal
To assess risk for aspiration if patient requires intubation/surgery
E: Events
To understand what happened to the patient leading up to now
This quick simple history can yield a significant amount of information, and can also be taken
from partners or family members coming in with the patient with relative accuracy if the patient
is unresponsive themselves. However, it is never an adequate permanent replacement for a
comprehensive medical history, and this should be completed at the first available opportunity,
either through collateral medical records or the patient themselves once stability has been
achieved.
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HOW TO OPERATE IN
SURGERY
Being a Med Student in the OR: Introduction ............... . . . . . . . 49

I. Finding the OR............................................................ 50
II. Costume change (scr ubs) .............................................. 51
III. First steps................................................................. 52
IV. Scr ubbing in............................................................... 53
V. Suiting up (gown and gloves) ......................................... 55
VI. Taking your position................................................... 57
VII. Keeping it clean (sterility protocols) ............................ 58
VIII. Helping out (retracting, cutting, stapling/suturing) . . . . . . .60
IX. Cleaning up............................................................... 62
X. Wash, rinse, and repeat ............................................... 63
48
The CLERKSHIP GUIDE | How to Operate in Surgery
Being a Med Student in the OR:

Introduction
No, medical students are certainly not expected to know how to complete full operations, nor
even be able to identify every single part of the internal anatomy during a particular surgery.
However, they are expected to know how to handle themselves in the operating room and
surgical field, often with little instruction or orientation other than the 1 to 2 hours of teaching
given during the first week of 3rd year. As a result, many students find themselves lost, confused,
and too anxious to gain as much as they could from the experience of being in the OR itself.
This sections aim is to relieve some of that anxiety by orienting new students to surgery etiquette,
expectations, and general advice, while avoiding common pitfalls. It is organized in order of a
typical OR day experience, and describes what to expect in each step of the process. Although
not every OR is the same, nor every surgical specialty, in general much of the information here is
common to any experience in this somewhat new and foreign land.
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I. Finding the OR
Before entering the OR, you must find the OR. Luckily, the majority of ORs at hospitals happen
to be located on the 2nd floor (Im sure for some logistical reason unbeknownst to me). So a
good bet is to head there first and look for the signs. If you become lost, simply ask anyone
wearing scrubs (alternatively, you could follow them around creepily until they lead you to the
OR, but this is far less efficient). Youre looking for either some kind of front desk where OR
booking is so you can ask for instructions, or an unmarked door with some kind of keycard or
numpad lock on it that leads to the change rooms (although be careful as unmarked doors arent
gender-differentiable). Once you manage to get into the change room, youll be ready for the next
step before heading into the ORs just past the far change room doors.
Memorable Moments
I was in my peds rotation (second week of third year) working in the NICU. My preceptor and I were
called to a stat c-section. Being new to the OR scene I did not know where to find things or what to grab
running in. As we ran into the OR hallway, my preceptor handed me what I thought was a cap and said,
"Put this on your head." In 2 minutes the entire hallway full of nurses, doctors and one nervous dad
erupted in laughter. Apparently, there are beard covers you can wear in the OR, and while they look
stylish, they should not be worn on your head.
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II. Costume change (scr ubs)

More than just a funny TV show or something a 90s R&B girl group does not want, scrubs are
quintessential to surgery. They come in a multitude of sizes differentiated by the colours of the
trim and drawstring (most will opt for the yellow smalls or blue mediums), they are renowned for
their pajama-like comfort, especially for when on call. They usually come in a drab green or
blue, are stamped with a fading health authority logo, and can be found nicely folded in stacks on
a metal rack in the change room. So, grab a pair (ensuring you dont get 2 tops or 2 bottoms, an
easy mistake) and change it up.
Scrubs can be worn over light shirts and underwear or, for those of you who prefer complete
comfort, over nothing at all (if you can cope with the fact scrubs see a lot of sweat, blood and
who knows what else during their lifetimes, even if they are thoroughly cleaned each time).
Something to keep in mind about being a loose-fitting garment, is that modesty may sometimes
be of concern when leaning over while in scrubs, and thus opting for a smaller sized top may be
prudent (or as some nurses choose to do, using silk tape to secure their v-neck closed). Scrubs are
reversible, so dont fret about putting them on inside out. Typically 3-4 pockets are available for
keeping your valuables (ex. keys, wallet, cellphone) or other tools (ex. pen, paper, pager,
stethoscope) close to your body. Leave the rest of your stuff in or on top of a locker in the
change room as they arent welcome in the OR.
To complete the transformation, the scrub outfit requires a cap and shoe covers. Caps come in 2
types, surgeons and shower. You may feel a little pretentious to don the surgeons style
cap early on, but there isnt really any rule in regards to this. Most people opt for the shower
cap though simply because its the only one that can cover all of your glorious mane. Don't
forget shoe covers, especially for inherently messier specialties such as ObsGyn and GI surgeries.
Just in case, its probably still best to wear an older pair of runners than your brand new kicks.
Amniotic fluid or blood isnt shoe friendly.
51
III. First steps

Once youve gotten changed, its time to head into the unknown. Most operating wings are
arranged in a square or rectangular lay-out with the various ORs surrounding a central supply
core. Therell be plenty of signs around indicating where the various numbered ORs are. If you
already know to which OR youre headed, then you can go there directly, even if you accidentally
take the long way around the square. If youre not sure which OR youre supposed to be in, find
an OR slate print-out posted somewhere (often on OR doors) and figure out which room your
specialty service or surgeon is in. Now you can head there and youll probably also the long way
around (inevitable).
Before you enter the OR, look through the window to see if theres already a surgery in progress.
If yes, make sure you put on a facemask before you head in, or youll quickly be turned away by
the nurses. If the rooms still being set-up or is in changeover mode between surgeries, head in.
Bring a facemask just in case, as technically if sterile equipment has been cracked and is being
set-up, youre still a contamination hazard by the nurses book.
A quick aside on facemasks: there are a variety of choices available, but in the end its all about
comfort. The ones with the attached faceshields can be useful for those who dont already wear
glasses, but remember to crease the edges forward, lest you enjoy having plastic adhered to your
forehead sweat for hours during the surgery. Alternatively, you could always wear the disposable
plastic sheet glasses available. Regardless of the style, ensure you pinch the metal strip at the
bridge of the nose for a good fit (especially if you wear glasses, otherwise itll be like drinking hot
soup...)
If the surgerys on, just enter quietly and stand by the side until youre noticed by the surgeon and
are addressed. Introduce yourself as the surgery medical student, and that youve been assigned
to this OR or that doctor for the day. Theyll then provide further directions about where to stand
for the best view (often by the head where the anesthesiologist stands, but be sure to not obstruct
his/her way). The surgeon will usually also give a brief blurb about the current patient and
procedure. Be prepared to be asked questions during the surgery as youre watching!
If the rooms being set-up by the 2-3 nurses (1 scrub nurse and 1-2 circulating nurses), introduce
yourself and put your name on the board along with your glove size (more on this later). Check
with the nurses regarding who the next patient will be (the slate order is sometimes changed up),
and read the chart for the patient history. If theres even enough time to do so, you might even
use the computer or a reference book to look up some relevant anatomy and surgical steps of the
planned procedure.
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IV. Scr ubbing in

At some point during your experience in the OR, the attending surgeon will offer you the chance
to scrub in, either to assist or for a better view of the operation. There will be no reason for you
to ever decline (even if you want to), so be prepared to get sterile and jump in on the action.
When you do get the chance to scrub in, the first step is to let one of the nurses know youll be
scrubbing in so they can grab an extra gown set, and then you should go into one of the
cabinets/drawers to grab gloves in your size and open them for the scrub nurse to take.
Scrub areas are outside each operating room, and a variety of scrub products can be found placed
or mounted above the scrub sink. The faucets will either have a motion-activated sensor, or will
be controlled by the U-shaped switch below the sink (you use your leg to turn this on/off). In
general, there are two methods of scrubbing in, each with their own pros and cons:
1) CHLORHEXIDINE OR OTHER ANTISEPTIC WET SCRUB

Method: First grab a scrub pack, open it, and immediately toss away the nail pick. Very rarely
will this be needed, unless you have very long nails, you were just working in the garden, or you
just finished mining for gold in your nose-cave (ew?), and have very visible dirt under the nails.
If so, do keep the nail pick to clean out the gunk from beneath each nail. Remove any rings,
watches, or bracelets from your hands before you start.
Next, wet your hands and the Chlorhexidine sponge, and use it to lather up your hands and
forearms. Then flip it over to the scrubby side, and give yourself a nice exfoliation treatment.
Dont miss any spots. This means scrubbing each of the 4 surfaces of each finger, as well as the
fingertips and fingernails, the back and front of each hand, and all 4 surfaces of each forearm all
the way to above the elbow. This should take you at least a minute and a half to do properly (any
less and youre cutting corners).
Now for the trickiest part: the rinse (where most mistakes occur). Your hands should be raised to
be above your elbow. Under the running water, run your hand through the stream while still
keeping your arm angled up (elbows down), and rub the fingers of that hand together to get the
soapy bits off. Carry on rinsing down your hand, wrist, then forearm until you get to your elbow.
Now repeat the same with the other side.
Remember, arms are always tilted up with hands above elbows, do NOT accidentally touch the
faucet with your raised hand when youre rinsing down to the elbow, and definitely DO NOT
grab paper towels after the rinse to dry off (normal habits can mess you up). Mess up with any
of these, and youll get the chance to practice the whole thing over again (mandatorily)!
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Pros: Can get under the nails and clean the fingertips well. Exfoliation. Allows for more
talk time at the scrub sink. Makes you feel like a surgeon to do it the classic way.
Cons: Can be harsh on the hands after multiple scrubs. As a wet scrub, it requires an
extra step before suiting up in your gown and gloves. Wastes water.
2) DERMOTAN AND MANORAPID DRY SCRUB:

Method: This is a combination method, in which you first wash your hands using Dermotan
soap to remove any gross contamination and dirt. This step usually only needs to be done once
at the start of the day, and only repeated if hands become visibly soiled or you leave the OR wing
and go to other areas of the hospital. You can use a similar method as the Chlorhexidine
method, but you dont need to be as meticulous in scrubbing every surface of your hands (but do
make sure you get under the nails, and use a nail pick if necessary).
Once your hands are cleaned, dry them off with paper towels, which you ARE allowed to do in
this method, and in fact should do quite thoroughly (residual water dilutes the solution in the
next step).
Pump 3-4 squirts of Manorapid alcohol solution from the dispenser into the cupped palm of one
hand. Dip the fingers of the other hand into the handful of Manorapid, then rub the handful
onto the front and back of the hand, and around each finger and the wrist. Use your still unclean
elbow to pump a few more squirts into your cleaning hand, and use that to rub down the forearm
to past the elbow. Repeat with the other side by using your unclean elbow to pump into the now
sterilized hand, clean the hand and arm up to the elbow, then using the elbow take the last few
pumps to do a final clean of your hands.
Air dry with your arms held above the waist. You may see some doctors wave their hands
around to speed up drying process, and although this isnt likely a big issue, one could argue this
increases the contamination risk by generating air turbulence that could stir and pick up more
dust/bacteria in the air. Safer to just let your arms air dry (or do very small waves rather than big
motions).
Pros: Quicker. Less harsh on your hands than repeated washing through the day. Dry
scrub means no need for the towelling dry step before you gown up.
Cons: Manorapid smells quite strongly of alcohol and can make some of you woozy if
you inhale too much. If you have any open cuts or wounds on your hands or arms...ow.
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V. Suiting up (gown and gloves)

Once in the OR, head towards the scrub nurse to put on your surgical gown and gloves. As
courtesy, wait your turn until the surgeon and resident are gowned up before you do (unless
theyre still outside scrubbing in). The scrub nurse will open up your gown and present it to you,
so stick your arms into the sleeves, but DONT put your hands all the way out of the cuffs! The
circulating nurse will then button your gown at the neck and tie the inside strings at the back.
Meanwhile, the scrub nurse will be stretching open your right glove for you, so stick your hand in
while at the same time pulling your sleeve up so your hand slips through the cuff into the glove.
Dont worry if you miss the correct glove finger holes at this point, just leave it be for now (to
date my perfect gloving record only happens 10% of the time still). When the scrub nurse
stretches the other glove open for you, pull it open even wider with your glove hand to put your
remaining hand in (again likely missing the correct finger placements).
Now you can adjust your gloves with your hands to make everything fit right, and pull on your
sleeves to get them out of your hands way (but dont pull them past the gloves cuff, youre trying
to form a tight clean seal there!) Repeat the whole process if youre wearing more than one pair
of gloves. If youre wearing a disposable paper linen gown rather than a typical cloth gown, be
careful you dont pull too hard on your sleeves when adjusting, because you CAN tear the gown
(Ive done this before...) and this will result in you having to rescrub all over again (along with a
somewhat annoyed nurse and an embarrassed you).
Once youre all set and your gloves are comfy, the last step is to tie up your gown completely (this
is a common step to forget to do, at least it was for me). Theres a cardboard tag at the front of
the gown holding the front strings. Pull this apart with both hands, one hand holding onto the
short string, the other hand holding on to the tag. Give the tag to someone, usually the scrub
nurse, but if shes busy the circulating nurse can do it, as long as you leave a large portion of the
card for her to grab on to. You then spin in the direction that wraps the tagged string around
your back to close the gown around you and brings the string back to your front/side (usually
counterclockwise spin to your left). Grab the tagged string as the nurse pulls the tag off, and tie
to the short string youve been holding onto this whole time. The key to the whole process is to
not let any of the strings drop because you didnt hold onto it at the appropriate times. Once
completed, youre ready to get in position.
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Heres a quick segment on glove size and choice. Typical sizes range from 6s to 10s,
corresponding to hand size. Some ORs will have a glove sizing chart posted, but if you dont see
one youll have to play it by trial and error. There are also half sizes to better fit hands, so try a
few times with different sizes until you find the right one for you. For reference, as a guy with
average sized hands and fingers, I wear size 7.5. They also come in brown or whites, which
generally corresponds to hand shape (browns generally have longer finger to palm ratio than
whites do). If thats not enough, they also come in different materials, such as latex, vinyl, or
Neoprene (for those with latex allergies). Therefore you should test out different gloves when
you get the chance to find whats right for you.
Theres also the question of whether to wear 2 pairs of gloves or 1. Some surgeons opt for two,
partly because it provides for more safety in case the outer pair is cut or torn, but also for
convenience since if the outer pair becomes contaminated somehow, they can pull that pair off
and put on another glove without having to scrub out as their hand is still covered by the sterile
inner glove. Those who opt for only 1 pair prefer it as its less hassle, and offers more sensitivity
and control to their hands if they need it. Some choose to wear a pair of clear plastic liners on
the inside of an outer pair of surgical gloves, out of preference and comfort. Typically the outer
pair of gloves will be a half size larger (or be a pair of browns) versus the inside pair, if opting to
wear two pairs. There is no right or wrong to this, and comes down again to personal preference.
I choose to wear only 1 pair of 7.5 whites, partly out of convenience/comfort, but also because I
have enough trouble getting one pair of gloves on smoothly, let alone two...
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VI. Taking your position

After youre gowned and gloved, keep your sterile hands crossed on your arms or gripping the
front of your gown. Wait until the surgeon and assist/resident has prepped the surgical area and
draped the patient. Once theyve done so and have stepped into place at the table, theyll usually
direct you to where the best place for you to stand is. In general, only 4 fit easily around the
table, and the scrub nurse needs their room as well, so at times you may find yourself further
from the surgical field or viewing from a somewhat awkward position. If you have a space to do
so, put your body right up against the table edge, and your hands on the drape.
Sometimes you may be asked to move or switch to the other side of the table. When this occurs,
back yourself away from the surgical field with your hands crossed on your arms or held up, and
shuffle around. Your front should always be facing the sterile field, unless you need to cross
behind someone, in which case spin so your backs are facing each other and you can move into
position on their other side. If you ever need to go around equipment to get to the other side,
take the long way around, and NEVER cut in front of a scrub nurse and his/her surgical
instrument table (thats the quickest way to a reprimand from them).
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VII. Keeping it clean (sterility

protocols)
Theres a lot of easy mistakes to make when it comes to breaking sterility, and its near inevitable
that you may trip up at some point or other (Ive certainly done it more than once...). The most
important rule of thumb is think before you touch. Ask yourself before you touch anything
new, is this sterile? Other principles include sterile heights, which is set at the highest point on
your gown that has been below table level at some point. This means if you sat down for a part
of a procedure, you arent allowed to stand back up over the field, as your upper body is now
contaminated by being below table level. Similarly, anything below the waist is regarded as nonsterile, so dont ever let your hands drop down to your sides.
Itchiness, slipping glasses, or sweaty foreheads also pose a common dilemma. Youre certainly
not allowed to use your shoulder to scratch that itch, push up your frames, or wipe the forehead.
In these situations, you either tough it out, ask for help, or get innovative. Try fidgeting a bit to
scratch against your gown, or wrinkling your nose to get some facemask friction to ease a nose
itch. If neither method works, just ignore it and likely itll go away on its own. If not, youll have
to ask the circulating nurse to help you out by scratching, or similarly pushing up your glasses or
wiping your forehead. This can be a little embarrassing, but thats why it helps to have been in
the room earlier and have introduced yourself to the nurses before the surgery. In terms of
innovation, some have used various objects in the room to aid them, such as pushing your glasses
up using the edge of a tv monitor or cart, as long as you dont touch it with your gown. You may
get weird looks or teased for it though, but its all in good fun.
Although youre allowed to cough or sneeze as you have a facemask on, its polite to face away
from the surgical field when doing so, and you may still feel awkward or embarrassed in the
process. If you unfortunately are sick with a dry cough at the time, its best to have lots of
lozenges with you for the day. One or two in the mouth prior to scrubbing in will hopefully hold
you over for most of the surgery.
If you ever feel faint or lightheaded during a surgery for whatever reason, there is no shame in
admitting so and asking to leave the surgical field, even if its temporarily to take a breath. As
many a surgeon has said, theyd much rather you scrub out and sit down than passing out on
their surgical field (too much paperwork if that happens). You can always scrub back in when
youre feeling better.
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Lastly, should you ever accidentally break sterility, whether someone notices or not, own up to it.
Step away from the table, admit you just contaminated yourself accidentally, and ask if you
could go re-scrub and come back in. No surgeon or nurse will ever fault you for being responsible
when it comes to patient safety (and if they do, youre still in the right). If youre unsure if you
broke sterility, ask. Its a bit of extra time and effort to avoid the possible, even if slim, risk of
serious complications from surgical infection. We owe it to the patient as part of the medical
professional team.
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VIII. Helping out (retracting,

cutting, stapling/suturing)
Having scrubbed in and standing in position, you may be asked by the surgeon to help out at
various times. Dont expect to be doing anything major, especially since most of the time there is
an assist or a resident around. In general, students will be asked to hold retractors at various
times throughout the main part of the surgery. Keep good tension on the retractor so a good
surgical view is maintained, and dont worry about pulling too hard since skin and connective
tissues are pretty durable as long as the retractor is placed in the right position initially. Also do
remember to change your grip or hand once in a while, otherwise your arms will fatigue quickly.
At some point in the surgery, usually during the closing process, tied sutures will require cutting.
Heres where you can be a hero! Often nurses will pre-emptively tap your hand with the handles
of the scissors, so take that as your cue to take the scissors and be at the ready to cut. Otherwise
the surgeon will take the scissors and pass them to you, so be at the ready either way. Suture
cutting isnt rocket science (or brain surgery, for the neurologists among you), as long as youre
aware of some guidelines:
1. If you ask how long when the surgeon asks you to cut, you may get as long as it needs to
be as an answer in return. Instead, watch for some subtle cues carefully, such as the surgeon
doing a quick tap with the needle drivers or forceps on the suture line they want cut at the
location they want it snipped.
In general, internal closing sutures and dissolvable buried sutures should be cut short (just above
the knot), external simple interrupted skin sutures should have about 0.5cm left to the ends, and
any temporary suture used to pull or manipulate structures around should be cut ABOVE where
the clamps/hemostats are clipped.
2. When you need to cut a suture short just above the knot, bring the scissors right down on top
of the knot, then tilt the scissors to angle the blades 45, then snip. This ensures you dont cut the
knot, and theres enough tension in the remaining suture length that the knot wont slip. This
trick will generate more trust in you by your surgeon, even if they dont compliment you on it
specifically!
3. No blind cutting. If you cant see the suture notched into your scissors blades as you cut, along
with the tips of your blades, you shouldnt be closing those handles. Nothing worse than
accidentally cutting a structure you didnt see (especially if its a vessel!). Better to readjust your
hand or body to get a good view, and if you still cant see, mention it to the surgeon and theyll
direct you as needed based on their preference (they may still say thats ok, just cut)
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4. Along with suture cutting, you may be asked to help as the surgeon/resident sutures, usually
by doing something called running the line or follow me. This simply refers to them wanting
you to hold onto the suture line to hold tension in the previous loop/knot as they put in the next
loop during continuous running sutures. Gently tug on the suture line so its taut, but not pulling
excessively on the tissue itself, and once the next loop is in, let go so the suturer can pull it tight.
Grab onto the suture line again once theyve made their pass through and are setting the needle
for the next loop.
5. At some point you may be asked to demonstrate your knowledge on sutures, including types of
stitches, knots, suture size and material, needle shapes and sizes, and relations to tissues. This is
where some pre-reading helps (use the super colourful manual the faculty gave us to learn).
When its time to close the outermost skin layer, you may be offered the chance to either help
with the staples or do some actual suturing yourself. Using the staple gun is relatively
straightforward. The surgeon/resident will use two pairs of forceps to grasp the skin edges and
bring them together. You place the staple gun centred and parallel to the skin surface just behind
where the forceps are, and squeeze the trigger to close a staple everting the skin edges. DONT
let go of the trigger quite yet! Add a little bit of backwards traction and wait until the
surgeon/resident re-grasps their forceps onto the next portion of the skin edges. Close another
staple in the next location, and repeat as necessary until the entire incision is closed.
If you get the chance to suture, make sure you know how to do a vertical mattress and a buried
stitch, as these are usually the ones used for closure. Also know how to do 1 or 2-handed ties, not
just instrument ties! Practice, practice, practice until the hand movements become second nature
and you understand how the knot gets tied when you manipulate and rotate your hands. I
practice by using floss on anything you can loop the floss around (ex. pencil), and tying
repeatedly (as a bonus, you dont need to unknot the whole line at the end of the day, since you
can just toss the floss).
On the very, very rare chance you get an opportunity to hold a laparoscope camera or
instrument, you will become disoriented with the 3-D space, as the hand directions get reversed
on the internal side (envision the fulcrum of the instruments at the skin and muscle tissues. If
youre operating the camera, always have the center of the field focussed on the place of action in
the body. Make sure your camera view is vertical and perpendicular to the horizon level, and
definitely, definitely dont shift/shake/fidget around too much, unless you want to make everyone
viewing nauseous and dizzy!
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IX. Cleaning up
Once the surgery is complete, the surgeon will usually have already de-gowned in order to go sort
out the operative note and dictation and prepare for the next patient. That will leave you and the
assist/resident to tidy things up tableside, which generally involves wiping the incision site clean,
applying dressings (ex. steristrips and gauze bandage), removing all the drapes and cleaning up
equipment. Therell then be a bit of a break while the anesthesiologist brings the patient out from
under anesthesia, during which time you can chat with the resident and have any questions you
had answered. Keep in mind though that theyll also be busy writing the operative note and postop orders, so see if you can help in any way with that first before you distract them with
questions. You should also bring in the patient bed if it hasnt already been done and bring it
beside the surgical table in preparation for transfer. Once the patient rouses, put a pair of nonsterile gloves on, and get ready to help roll the patient up on one side, shove the slide table under
them, and drag them onto the patient bed. Youll be told by the nurses and anesthesiologist
where to stand and what to do, so follow their directions. Once the patient is safely in the bed,
the patient will be brought to the post-anesthesia care unit. Depending on your resident, you may
follow them to the PACU while the OR is being cleaned and reset, or you may go see the next
patient on the slate to get properly prepared.
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X. Wash, rinse, and repeat

All in all, thats the gist of the surgical day process, and you repeat this until all the surgeries on
the slate are complete. In between surgeries, you should also try to find some time to check on
the patients post-op in PACU to ensure theyre doing alright and there are no worrisome signs
present (ex. hypotension, tachycardia, bleeding through bandages). Any given surgery day may
have anywhere from 2 to 8 patients, depending on the surgical service and the
length/complexities of the surgeries.
Definitely look for any opportunity you have to sit down, as your back would really appreciate it
by the middle of the day. Also go grab food quickly when you can and use the washroom, since
you never know for sure how long the subsequent surgery may take before you get a break. In
this way, youll survive your surgical days. Theres plenty more to learn and pick up, but those
come from experience, and you certainly wont be expected to be rock stars and know everything
beforehand. However, hopefully after reading this section, at least theres less anxiety about the
possibility of making a total fool of oneself in this unforged territory!
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WELLNESS
Edited by Diana Kang, Andrew Wong, and Lawrence Haiducu, MD 2014
Protecting yourself with insurance ..................................... 65

Finding a place to relax.................................................... 66
Suppor ts available to you .................................................. 67
How to fit in exercise....................................................... 68
Biking to the hospitals ...................................................... 69
Where to find good healthy eats ......................................... 71
General wellness tips........................................................ 75
64
The CLERKSHIP GUIDE | Wellness
Protecting yourself with

insurance
Anna Aquino, BCMA Student Advocate, MD 2014
Congratulations on making it to your third year! Youre even closer to being the doctor you have
always dreamed of you get to treat real patients from now on! Its sure to be an exhilaratingly
busy year.
Before you immerse yourself in learning to care for others, take a moment to think of yourself.
Commutes youll have to take whether by transit, driving, biking, or with your own two feet.
The stress youll undoubtedly feel crushed by at some point over the next year. The bustling,
hectic environment of hospital hallways, ERs, ORs, and wards. Not trying to sound like a Debbie
Downer, but you may be faced with many challenges that knock you down health-wise: a broken
bone from an accident, stress so overwhelming that you just need to take a break from it all, an
unexpected needle prick. If you need to take extended time away from clerkship for your health,
what happens to your loans and lines of credit? Likely, youll be required to start payments or
worse, you wont be able to draw out funds.
Disability insurance, to the rescue! If youre not able to attend clerkship or school for over 90
days due to an accident, illness, injury, or even stress, you could be eligible to receive disability
insurance benefits. Disability insurance provides monthly tax-free payments to help you cover
your living, schooling and medical costs until you get back on your feet. Recovering from illness
or a stress episode is not the time to be worrying about how youll pay your bills. The BCMA
offers an affordable plan to students ($2,500 of monthly coverage for only $125 per year if youre
under 40), and you dont have to answer any questionnaires or have a medical exam done. You
likely enrolled in the BCMA Student Disability in first year, but if you didnt renew your policy
you may no longer be covered. Check your insurance status by calling BCMA at 1-800-665-2262
or emailing BCMAInsurance@bcma.bc.ca . You can also book an appointment with one
of BCMAs Insurance Advisors who will gladly meet with you in person, over the phone, or via
the net to discuss your insurance questions and needs. Dont worry, theyre not pushy - theyre
non-commissioned employees of the BCMA working for members.
Remember, now is the time to make sure you are protected so you can focus 100% on your
studies.
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Finding a place to relax

There will be moments (perhaps too many of them) when youre feeling overwhelmed, burned
out, and in need of a break. Most hospitals are pretty busy and it can be difficult to get away from
the chaos even for a couple of minutes, but there are ways to do it!
Go for a walk. If you can find the time, get outside and breathe some fresh air!
Sit in the courtyard (if your hospital has one). Some hospitals, like St. Pauls and RCH,
have lovely courtyards that offer a quick outdoor escape right on hospital property.
Go to your call room. Sometimes the call rooms are a bit far away, so this isnt always
possible, but if you have the time, its a good place to shut out the rest of the hospital.
Find an excuse to visit a quieter area of the hospital. Radiology and pathology are two
areas that you might be able to find a reason to visit, and they are usually pretty quiet
compared to the rest of the hospital!
Go to an upper floor and check out the view for a couple of minutes. Looking out at
English Bay (St. Pauls), False Creek (VGH), or the Fraser River (RCH) provides a calming
break during a busy day.
When in doubt, go on a washroom break. No one can fault you for heeding the call of
nature, and doing so offers a few minutes away from your work!
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Suppor ts available to you

If youre starting to feel overwhelmed by everything, try talking to someone about it to receive
some moral support. Here are a few suggestions on who to go to when you need that extra
encouragement:
YOUR CLASSMATES
These people know what youre going through and can sympathize, so dont be afraid to talk to
your peers about how youre feeling! Chances are theyre having similar feelings about everything
you are experiencing in 3rd year. Talk to each other, vent, share coping strategies, and youll be
surprised at how quickly youll feel better!
RESIDENTS
If you find a resident that you get along well with, they can be an excellent source of support.
Theyve gone through what youre going through and survived to tell about it, so they may be
able to offer you some advice and motivation.
SITE DIRECTORS/PROGRAM ASSISTANTS

The people in charge of your site and/or rotation are a good option if that overwhelmed feeling
is either related to the expectations of the rotation or is affecting your performance. If youre
upfront about how youre doing, youll be more likely to get some help dealing with all the
requirements. Its far better to let people know youre struggling as soon as you run into trouble
rather than trying to explain when you get a not-so-hot grade or assessment!
OFFICE OF STUDENT AFFAIRS

As always, the people at the OSA are here to help and offer support and advice as you navigate
medical school. You can speak to them confidentially about how youre doing and theyll be able
to help you figure out the best way to manage.
AN INDEPENDENT COUNSELOR
If you have health insurance, usually you will have enough coverage to go to about 3 sessions
with a qualified counselor or psychologist without having to pay for it yourself. Talking to
someone who is completely separate from your medical school life has its benefits and may make
a big difference to your sanity! You can search for counselors online (make sure they are
qualified!) or ask your family doctor (or Student Health at UBC) for a recommendation.
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How to fit in exercise

With long hours at the hospital, long hours of studying, and trying to fit in some family & friend
time, exercise might fall to the bottom of your To Do list. If you can, taking time to get to the
gym, go for a run, or attend a yoga class (yoga and MedFit classes take place weekly at the
MSAC - watch your med-all e-mails for details!) will likely do a lot of good for both your mind
and body. But what if you dont have time to do those activities (and you cant bear the thought
of getting up an hour early to make time)? You can incorporate exercise into your day so that you
stay healthy without having to take the time to work out. Bike or walk to work if you live close
enough to do so. Take the stairs instead of the elevator (in places like St. Pauls, youll probably
get to your floor faster anyways!). If there is a gym on site or nearby, you could do a quick
workout over your lunch break. Stand while you write your notes and take a second to stretch.
Tense and release your muscles to keep them working during rounds. Every little bit counts!
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Biking to the hospitals

(Thank you to Heather Taddy, Lisa Howard & Niky Hatfield for the information)
VGH:
A bike cage is available in the Diamond Parkade. You need your VGH ID card to be activated by
security so that you can access the bike cage and the adjoining locker rooms.
The door to the locker rooms is located across from the door to the elevators on the first floor of
the parkade. There are lockers and showers available. There are limited lockers so if you are not
at VGH for a while please remove your lock to leave space for others.
There are also showers available in the OR change rooms and the Call Room area.
Lastly, dont forget about bike parking in the MSAC courtyard (access with VGH ID). Showers
and lockers are available in the basement. This is the best place to park and shower when heading
to BCCA.
SPH:
A bike cage is available in the SPH parkade off of Burrard. You need a Providence ID card to
access it. These cards are available from the ID/security people on the 4th floor of Burrard
building.
Showers are located in locker rooms of 4th floor of Burrard just outside of the eating disorder
clinics. There are also showers in the call room area (6th floor Burrard) and in the OR change
rooms. You need your Providence ID to access all of these.
There are lots of lockers in the new call room area - bring your own lock.
BCCH/BCWH:
A bike cage is available in the parkade located under the entrance to labour and delivery (south
side of building). You need a key to access it. You can purchase a key for $10 (theyll give you $5
back if you return it) from the cashier office (from Tim Hortons walk down the hallway towards
Childrens hospital, office is just past the first elevator on the left.).
Showers and lockers are located on the second floor of BCWH (right side of hallway as you walk
from childrens to womens). Mens locker room is to the right through glass doors. There are also
showers in the Childrens hospital call room area (by the cafeteria) and the OR change rooms.
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UBC HOSPITAL:
Bike cage is at the hospital parkade or in the parkade across from the Life Sciences Center (Go to
the UBC trek office for the code). Showers and lockers are in the Life Sciences center and OR
change room in the hospital.
RCH:
A bike cage is located in the parkade (entrance off Keary St.). A key card is provided as part of
ID at the start of the rotation, but you have to ask SPECIFICALLY for the one that opens the
bike cage; not all of the cards do this.
Lockers and showers are in the student/resident lounge.
RGH:
The bike cage is located on the ground floor of the multiple storey parkade. Access is via your
VGH ID that you can have coded from the Parking and Security Office. Ask at the info desk for
directions, but it is farther down the same hallway used to access the OR locker rooms.
If you are on a surgical rotation, it is most convenient to use a visitor locker in the OR change
room, and there is a shower there. There are also call rooms upstairs by the wards with showers
and lockers.
LGH:
The bike cage is located in the corner of the ground level parking lot. To access it turn in the
driveway off 15th Street. Keys to the bike cage are available from the Cashier inside the door
closest to the bike cage for a small deposit.
Small lockers are available near the Doctor's lounge/mailboxes on the main floor of the hospital,
or in the OR locker room. Showers are available either in the OR locker room, or in the call
rooms in the tower near the wards. Towels are provided. The education assistant who will be
emailing you with your rotation information can show you where the lockers/call rooms/etc are.
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Where to find good healthy eats

To quote a wise medical student, If you dont eat, you wont think... thats bad.
Maintaining regular and healthy eating habits is important as you work through crazy hours in
the hospitals. Always take time to eat, even if its just a 10 or 15 minute pause to eat your
sandwich. Most preceptors and residents are good about making sure you get breaks to eat, but
dont be afraid to ask for the time if they havent noticed that your stomach is growling!
The best way to be sure youre eating healthy, inexpensive food is to pack your own. Sandwiches
and salads are quick and easy options, but most sites give you access to a fridge and/or a
microwave, so you can get a little more creative with your food choices as well. Try to put
together your food the night before to save time in the morning. Having a granola/power bar or
other quick snack in your pocket or bag is a good idea, too, for those times when you might not
be able to grab a proper meal when you start feeling hungry.
If you need to buy food (and, lets face it, it can be tough to pack enough food for those crazy 28
hour call shifts!), there are usually a few options at each hospital.
VGH:
The cafeteria is on the second floor and has a variety of options including sandwiches, chicken
fingers, stir fry, and pizza. Cafe Ami is also on the main floor by the 12th Ave entrance, which is
basically a coffee shop that also has various sandwiches, yogurt, and other snacks. If you have
time to venture outside of the hospital, there is a Tim Hortons on Broadway, Minato Sushi at
Oak & Broadway, and a Subway very close to Minato. There are also several Thai, Japanese, and
Indian food restaurants in the area. The Indian restaurant at Broadway & Willow has $5 lunch
box specials! Starbucks is in the Diamond Centre.
The call room has a fridge and microwave. If youre on your Surgery rotation, there are also giant
fridges as well as microwaves in the OR lounge. Microwaves can also be found in the cafeteria.
SPH:
St. Pauls boasts a wide array of yummy and quick food options in the vicinity, especially if you
have time to wander over to Davie St. There are Starbucks locations at Davie & Thurlow or at
Howe & Helmcken. Tim Hortons is at Davie & Howe. There is a cafeteria on the 4th floor of the
Providence Building, but the selection is limited.
The call room has a fridge and microwave that students can use.
71
BCCH/BCWH:
Youre going to want to pack lots of food for when youre at BC Childrens & Womens Hospitals
because the food options are sorely lacking. The cafeteria is on the main floor on the Womens
side (which closes at 6pm), and there is an On The Go Tim Hortons in the Womens lobby (but
they dont have all the sandwiches and everything that a full Timmys would). A Second Cup
coffee shop is located in the Childrens main lobby with some decent paninis and other
snacks,and they are open the latest of all the food places (10 or 11 pm). Starbucks is in the
Ambulatory Building but closes relatively early, so make sure youre armed with your own snacks
and coffee for overnight call shifts! There is a Safeway at Oak & Kingsway, but thats pretty much
it for food in the area.
There are fridges & microwaves in the mini-kitchens on the wards that you can use, and theres
also a microwave in the call room.
RCH:
The basement houses the not-so-great cafeteria, but there is also a Tim Hortons on site.
Starbucks, Subway, sushi, pizza, and a deli are all nearby.
RCH also boasts a fabulous resident/student lounge in the basement with a fridge, microwaves,
toasters, and even free food (cereal, milk, yogurt, bagels, cheese, fruit & juice are usually in
stock).
RGH:
The cafeteria is on the 2nd floor and there is a Starbucks right in the hospital. Most other food
options are a bit of a hike outside the hospital - Mad Greek is about a 5 minute walk away, but
tends to be on the expensive side.
There is a lounge shared by students & staff and in the hallway by the lounge are a fridge and
microwave.
SMH:
Youll find the cafeteria on the 2nd floor (it has good breakfast & lunch options), and there is a
coffee shop with Starbucks coffee right next to the cafeteria. A Tim Hortons is across the street on
King George Blvd.
The resident/student lounge on the 3rd floor is quite nice and has a fridge and microwave for
your use.
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LGH:
The cafeteria is on the 1st floor at Lions Gate, but the hours are pretty limited. There is also a
coffee shop in the hospital, but its not the greatest, so you might want to head outside to the
Starbucks, Blenz, or Tim Hortons which are fairly close by. There are lots of food options nearby
as well, including Thai food, sushi, Subway, and Nandos Chicken.
There are fridges and microwaves in the call rooms, in Labour & Delivery, and in the OR lounge.
UBC HOSPITAL:
The UBC hospital is a small one so on-site options are limited, but its very close to both the
Student Union Building, where there is a Starbucks and a small food court, as well as The
Village, which has quite a few food options.
KGH:
Kelownas hospital has a coffee shop and a cafeteria on the main floor. Otherwise, youre looking
at a 5 minute drive or 20 minute walk to find other food options at Pandosy Village (including
Subway, a pub, a coffee shop, and a couple other restaurants).
Unfortunately, theres no access to a fridge or microwave at KGH.
MILLS MEMORIAL HOSPITAL:

The cafeteria in the basement has okay food. Tim Hortons is a 10 minute walk away, and
everything else is about a 5 minute drive. Ankas and Don Diegos are good options.
The student lounge has a small kitchen you can use.
VERNON JUBILEE HOSPITAL:

The cafeteria is in the basement of the old tower, but has strange hours (its open for breakfast
and lunch but closes around 1300 and is only open on weekdays). The food, however, is decent
and the prices are reasonable. The Crack Pot Cafe is on the main floor of the hospital (open
0600-1900 and a little pricier than the cafeteria), but there is a Starbucks as well as wraps, a 24hour Subway, and an Earls at the bottom of the hospital hill (about 500 m from the hospital). If
you walk another 4-5 blocks further north into downtown youll find Indian, Asian, Greek, and
other Mediterranean food.
There is a staff lounge on the 3rd flood of the new tower where youll find a fridge, microwave,
and free cookies & coffee!
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CHILLIWACK:
The cafeteria is on the main floor, Starbucks is 2 blocks away, and multiple restaurants are within
a 10 minute walk of the hospital.
The doctors lounge is shared with students and has a microwave.
PRINCE GEORGE REGIONAL HOSPITAL:

The cafeteria is in the basement and includes a Tim Hortons. Second Cup is a 5 minute walk
away, as are Pita Pit, Quiznos, Booster Juice, Pizza Hut, a Chinese Restaurant, a Vietnamese
restaurant and a small soup/sandwich place.
The student lounge on the 5th floor has a fridge and microwave.
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General wellness tips
Talk to your peers - they understand what youre going through and can be a huge source
of support.
Make your health a priority. Make sure you eat proper meals and get a decent amount of
sleep on your non-call nights. Studying is important, but it wont be overly effective if you
cant think straight because youre tired or hungry!
Try to make time for friends and family, as well as for an activity that you enjoy that isnt
related to medicine. Its important to maintain a bit of balance, even though 3rd year tends
to be weighted heavily on the medicine side of life. Dont wait until youre completely
overwhelmed to ask for help. As soon as you realize youre struggling a bit, find someone to
talk to about it!
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SITES: VFMP
BCCH/BCWH: BC Children's & Women's Hospital . . . . . . . . . . . . . . 77
LGH: Lions Gate Hospital ................................................ 81
MSJH: Mount Saint Joseph Hospital ................................... 84
PAH: Peace Arch Hospital................................................ 85
RCH: Royal Columbian Hospital ........................................ 86
RGH: Richmond General Hospital..................................... 89
SMH: Sur rey Memorial Hospital ........................................ 92
SPH: St. Paul's Hospital................................................... 95
VGH: Vancouver General Hospital ..................................... 98
76
The CLERKSHIP GUIDE | Sites: VFMP
BCCH/BCWH: BC Children's
Hospital/BC Women's Hospital
Written by Erica Chhoa, MD 2014 and Aaron Gropper, MD 2013
Edited by Erica Chhoa and Jackson Chu, MD 2014
BC Childrens Hospital and BC Womens Hospital are both located on the same site in central
Vancouver. Although ultimately serving different populations, BCCH and BCWH are similar in
that provide very specialized care and are therefore ideal places to see pediatric and obstetric
cases respectively.
BCCH is the primary childrens hospital in British Columbia and therefore is not only the busiest
pediatric care center, but also the site most likely to provide you with the greatest breadth of
pediatric exposure. Because of its high volume, however, students are kept significantly busier
and work longer hours than at other pediatric sites. BCCH offers an unparalleled experience for
students interested in pediatrics but possibly an overwhelming one for students that rank
pediatrics low on their CaRMS list.
The large majority of patients that come to BCWH are peripartum. BCWH offers care to families
before, during and after pregnancy in addition to providing specialized treatment for high risk
pregnancies and infertile couples. If you choose to do the obstetric portion of your Obs/Gyne
rotation at BCWH (the Gyne portion is held at VGH) you WILL help deliver at least one baby
on most call shifts. Because there is always a mother in need of care of BCWH, expect to get
little sleep during call shifts. This is in contrast to other Obs/Gyne sites. However, if you
Obs/Gyne is your thing, you are strongly encouraged to complete the rotation at VGH/BCWH.
GETTING THERE
By car, BCCH/BCWH is about 10 minutes from VGH. Both Cambie and Oak St will take you
there in no time. Parking is available on site at a staff rate of $6.75/day. You can also park for
free in the surrounding area, although much of it is "residents only" or a 2-hour limit. There is
some non-restricted parking on the block northwest of King Edward and Oak St (on 23rd
avenue), or any of the streets west of Oak St. From these off-site parking spots, It is a 10 minute
walk to BCWH... or if you are really laze you can try to catch the #25.
If you decide to exercise your flashy UBC bus pass, the #17 will pick you up from the Children's
Hospital entrance and drop you off at the #99 or the skytrain station. Although it runs all the
way downtown, it is not the most reliable line so leave plenty of time. A second line is the #25
which runs along King Edward. The stop is a less than 10 minute walk to the hospital.
Alternatively, you can take any bus along King Edward Avenue or Oak St.
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Commuting from VGH or SPH is a breeze and there is a shuttle that runs between these sites and
BCCH/BCWH. The shuttles run every half hour and stop is at the entrance closest to
CFRI/CMMT. The schedule can be found here:
http://www.phsa.ca/NR/rdonlyres/92CA01DA-FDC0-49B1-955F2C8617FF718B/0/ShuttleSchedule.doc
STORING YOUR STUFF

BCCH
Pay attention during orientation as you will be shown where the lockers are! If you miss the
announcement, the lockers are on the 2nd floor.
BCWH
There are a few lockers available in the change room adjacent to the OR but there are rarely any
empty lockers. Your best bet is to cozy up to the nurses and use their space. Each ward, including
the admission area, has a secure nurses lounge. Often there is an empty cubby there to put your
belongings.
KEEPING CLEAN
BCCH
Youll find showers in the call room area, and there are towels in the back corner if you make
your way around the circle of call rooms.
BCWH
In addition to there being lockers (and towels and scrubs) in the change room by the OR, there is
also a shower. Although at first glance the shower looks quite basic, just a shower head, a tile
floor and a curtain, it becomes divine after a long night of deliveries...or one messy delivery!
CALL ROOMS
BCCH
The call rooms are in the medical student lounge, which is close to the cafeteria. Get someone to
show you where it is, because its a difficult location to explain! There are quite a few call rooms,
some of which are designated for a certain service (dont use someone elses call room or theyll
end up sleeping on the couch!).
BCWH
There are two call rooms located on the second floor. The rooms are very basic with a desk and a
bed. The resident that you are on call with should have the access code. When on call, the rooms
are a great place to store your belongings but dont count on much sleep!
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THE LOUNGE
BCCH
There is a lounge and kitchen area where the call rooms are. Theres also a new residents lounge
over by the walkway to the ambulatory building that is always stocked with snacks... but medical
students dont have access to it, so youll have to befriend the residents in order to get in!
BCWH
There is a residents lounge located on the main floor of BCWH. The access code will be
provided during orientation. This lounge is where morning rounds are held. The amenities are
pretty basic and include couches and a TV. Fridges and microwaves can be found in the multiple
nurses lounges.
THE CAFETERIA
The cafeteria is found on the ground floor of the hospital. It has a good variety of food and many
students rely on it daily. Sandwiches, salads, burgers, pizza, a daily special among other items are
what you can expect. Be sure to check the hours however so that you do not find it closed when
you are on call!
COFFEE!
There is a Tim Hortons, Starbucks, and a Second Cup all on site so you should never be without
caffeine! While the Starbucks and Second Cup are located in BCCH, the Tim Hortons is found in
BCWH. The Second Cup is open the latest.
GOOD EATS CLOSE BY

All of the coffee places will sell small treats in addition to sandwiches and other small meals. If
you prefer to venture off site, there are restaurants, a sushi place, and Safeway at King Edward
and Oak St which is only a 5-minute walk from the hospital.
THE LIBRARY
The library is on the second floor of BCCH and has many cubicles, chairs, tables for studying.
There is also a good shelf of reference materials and textbooks.
COMPUTERS
There are computers in the BCCH student lounge and in the library.
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OVERALL IMPRESSION
Located centrally, commuting to BCCH/BCWH is no more cumbersome that traveling to VGH.
Parking is cheaper too! While BCWH is small and easy to navigate, BCCH is large and often
takes some time to become familiar with. Both sites are busy, providing ample opportunity for
patient interaction, learning and hands-on experience. The staff and residents at both sites are
knowledgeable, freindly and excited to teach the keen student. However, they also have higher
expectations and are more demanding than at other sites.
80
LGH: Lions Gate Hospital

Edited by Erica Chhoa, MD 2014
Lions Gate Hospital is a community hospital serving the unique and diverse population of North
Vancouver. This comes with both advantages and disadvantages. The main disadvantage is that
the breadth of exposure is limited. For specialties like paediatrics and obs/gyne, this means a less
demanding schedule but more self study required. The advantage of working at LGH is the direct
contact with staff physicians. You can expect to play a much larger role in the care of patients
and surgical procedures.
GETTING THERE
LGH is a little out of the way for most but this does not necessarily mean that you need a car. If
you are driving, you can expect the trip to take about 25 minutes without traffic from VGH. As
long as traffic is quiet, the best route is over the Lions Gate Bridge and then east along Marine
Drive/Keith Road. Highway 1 is an alternative option and the travel time is very similar.
The LGH parking lot is accessible from E. 15th Street off of St. Georges Avenue. The staff rate is
$5.75/day. A temporary parking pass is required to get this rate and the pass is obtainable from
the Cashier on the main floor by Admitting. Parking within a four block radius of the hospital
has a two hour time restriction but there is free parking about 5 blocks from the hospital (past
18th Ave). There is also a free parking lot at the corner of Moody. Its about a 7-minute walk to
the hospital.
Using the wonderful Vancouver public transit system, you will have to first find your way to
North Vancouver using either the SeaBus or a bus that crosses the bridge. Once you are in North
Vancouver, the #230 and #229 buses both stop at Lonsdale & 13th, which is a block west of the
hospital. From VGH, an alternative is to travel to West Georgia downtown and transfer to the
#240 from there, which will drop you off at the 15th street entrance to the hospital. The trip is
about an hour long.
I have great admiration for any student that wakes up extra early and is prepared to get home a
little late, and maybe a little wet, because he or she uses a bike for transportation. If you are one
of these students, your bike will be well taken care of at LGH. The bike cage is located in the
corner of the ground level parking lot. To access it, turn in the driveway off 15th Street. Keys to
the bike cage are available from the Cashier inside the door closest to the bike cage for a small
deposit. Youll find plenty of hills along the way so ride is especially rewarding (and grueling).
81
STORING YOUR STUFF

Lockers are available and you can request one by sending a polite message to the person who
sends you your site information (currently Michelle Snyder) if you are not automatically assigned
one. The main lockers are located in the doctors lounge on the first floor but there are also
lockers near Labour & Delivery if youre on your Obs/Gyne rotation. Although there are lockers
in the OR, there are rarely any free ones.
KEEPING CLEAN
You will be able to find showers adjacent to the call rooms and in the locker rooms. Towels are
provided. Although it may seem silly now, nothing makes you feel more human at 3am then a
nice shower.
CALL ROOMS
The main call rooms are on the 4th floor of the main tower. Depending on your rotation, you
may be given access to other call rooms.
THE LOUNGE
Found in the 4th floor on-call area, it has both a fridge and microwave. If you are at LGH on
your Obs/Gyne rotation, the labour and delivery nurses' area is also available for your use. This
area also has a fridge and a microwave. In addition to the students and nurses there is also a
doctors lounge on the 2nd floor. You will be given the access code during orientation.
THE CAFETERIA
The cafeteria is located near the main hospital entrance on the first floor. It has limited hours so
make sure to bring food with you when youre on call.
COFFEE!
There is a coffee shop in the lobby of the hospital. However, it has been given very poor reviews.
Within a few blocks of the hospital on Lonsdale, youll find a Starbucks, Blenz and Tim Hortons.
GOOD EATS CLOSE BY

Lonsdale is your best bet to find a nice fresh meal outside of the hospital. Along this street there
are plenty of options on Lonsdale including Krua Thai, Sushi, Subway, Tim Hortons, Nandos
and Safeway.
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THE LIBRARY & COMPUTERS

There is a library on the first floor of the hospital near the video conference area. It is open
Monday to Friday, from 0800-1600 hours. 24-hour access is available through the Doctors
Lounge. In addition to computers, there is also UBC secure wifi available.
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MSJH: Mount Saint Joseph

Hospital
Written by Sabrina Eliason, MD 2013
GETTING THERE
Located just two blocks north of the No. 9 or No. 99 bus stop on Kingsway and Broadway.
STORING YOUR STUFF

There is no allocated area for medical students to store their belongings other than on the
ward/in the department (i.e. ER) they are working.
KEEPING CLEAN/CALL ROOMS/LOUNGE

No Call rooms.
THE CAFETERIA
A small cafeteria with limited selection of sandwiches, snacks and a daily hot entree.
COFFEE!
There is a small cafeteria on the main floor of the hospital
LIBRARY
None.
COMPUTERS
None that are allocated for personal study.
84
PAH: Peace Arch Hospital

Written by Anne-Marie Madden, MD 2012
GETTING THERE
Unfortunately, if you live in Vancouver, you are going to have to drive to White Rock. It took me
between 60-90 minutes to drive, depending on the traffic. The bus takes about 2 hours each way. I
was given a free parking pass for the month on my first day. You have to use the small parking lot
across from the Emergency Room entrance. Be sure to give it back at the end of the rotation.
STORING YOUR STUFF

I left my stuff in the staff room near the ER entrance.
LOUNGE
There is a fridge, kettle, and microwave in the staff room.
CALL ROOMS
The only rotation I did at Peach Arch was Emergency Medicine, so there wasnt any call.
THE CAFETERIA
There is a Tim Hortons on the main floor. I never checked out the cafeteria.
85
RCH: Royal Columbian Hospital

Written by Aaron Gropper, MD 2013 and Erica Chhoa, MD 2014
Edited by Charlie Zhang and Erica Chhoa, MD 2014
Royal Columbian Hospital, or Hotel Columbian as it is more fondly known (due to the luxurious
resident/student lounge), is smaller than VGH and SPH yet larger than other community
hospitals such as RGH and LGH. Most rotations are offered at this site and these rotations
generally tend to be more relaxed than those held at the larger hospitals. This atmosphere is due
to the residents and staff that work at RCH in addition to the patient volume. Although on some
rotations such as psychiatry you will be finished ridiculously early you can expect a normal work
day for most others. However, the patient load may be decreased and you may actually get some
sleep on call!
GETTING THERE
Although RCH is not located conveniently, it is fairly easily accessible by car, transit or bike.
From VGH, the drive to RCH takes about 25 minutes without traffic. However, with morning or
afternoon rush-hour, the trip can be as long as an hour. I would recommend heading to the
hospital early and using the extra time to round on patients, eat breakfast, study or catch up on
sleep! Similarly, both the library and student lounge are very comfortable places to hang out and I
would often head home later in the evening when traffic was minimal. Besides, nothing shows
that you are keen like staying at the hospital longer than your resident and attending! To get to
RCH, you can take Kingsway, Lougheed Highway, or Highway 1. Highway 1 has the fewest
lights but can also be the most congested during peak hours.
When you get to RCH, you can park either in the main underground lot or in the outdoor lot
adjacent to the hospital. With a staff parking pass parking is $5.75/day in the outdoor lot. This
parking pass is obtainable with a valid VCH ID. If you plan on being out at RCH for at least a
month, it is more sensible to buy a month's pass for $60 and park in the outdoor lot. To obtain a
pass, go to the administration office in the basement near the residents' lounge. Although parking
underground is slightly more convenient, it is also more expensive.
Although driving might be convenient, it can be expensive and take away from your precious
study timeor sleep. Fortunately, transit is a very viable alternative as the Sapperton Skytrain
station on the Millennium line is across the street from RCH. On a good day, you might choose
to take out your books and study or after a long day you might just take some time to zone out
instead.
If you are a bike enthusiast, the Central Valley Greenway will take you all the way to New West.
Once you arrive at RCH, you can park your bike in the bike cage that is located in the parkade
(the entrance to which is off Keary St.). A key card is provided as part of ID at the start of the
rotation, but you will have to ask specifically for a card that opens the bike cage, as not all of the
cards have this feature.
86
STORING YOUR STUFF

Part of the five star experience at Hotel Columbian is your own full size locker during each
rotation. Lockers are located next to the residents' lounge in the basement. If you forget your
lock, you can borrow one from administration.
KEEPING CLEAN
Showers are also located next to the residents' lounge. Towels are provided, although at this point
it is unclear how many students, if any, actually bother to take a shower.
CALL ROOMS
The call rooms are located next to the lockers and the residents' lounge (all located next to the
medical education office in the basement of RCH). They are quite nice, with comfortable beds
and pleasant lighting (hence the name Hotel Columbian). You can also grab extra blankets from
the hallway if you need to (that is, if you're lucky enough to get some sleep!).
THE LOUNGE
The residents' lounge at RCH is the highlight of the hospital, and it will undoubtedly enhance
your experience in any rotation! There are computers, phones, couches, TV, video games, a
foosball table, and a nice view of the Fraser River. The best part is that three times a week, the
communal fridge is stocked with goodies like bagels, cheese, cream cheese, ice cream, cinnamon
buns, milk and fruit juice. And the cupboards store cereal, biscuits, peanut butter and jam. There
is also a sink, microwave, kettle, another fridge for your own personal food, and a sandwich
griller! The griller is well seasoned (rarely if ever wiped down) resulting in a grilled cheese with a
flavour unique to RCH: The RCH Grilled Cheese Special. Delicious.
THE CAFETERIA
The cafeteria is also located in the basement. The food is decent and moderately healthy but the
selection is minimal. Most students recommend bringing a lunch or buying something off-site:
Subway, Quiznos, sushi, and pizza are all nearby. Also, don't be afraid to snack on the communal
food in the residents' lounge! Another important tip is to learn when free lunch is offered. For
example, during your Internal Medicine rotation, there are usually at least three if not more days
a week where lunch is provided (and it's usually tasty).
COFFEE!
There's a Tim Horton's in the hospital lobby, which is fantasticexcept when its being used as
overflow for emerg. If you insist on a barista making your quad grande non-fat extra foam
extra caramel caramel macchiato, Starbucks is north on Columbia. Before morning report on the
Internal Medicine rotation, coffee is offered free (because you WILL be pimped if you fall
asleep)!
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GOOD EATS CLOSE BY

Subway, Quiznos, sushi, salads, and pizza are all nearby. There's also a good Thai restaurant
down the street that your Attending might take you to (or order take-out from) if you're lucky.
Some students also take advantage of a nearby supermarket.
THE LIBRARY
The library is adjacent to the residents' lounge and has plenty of computers and study space. It
also has useful textbooks that you can borrow for a couple of weeks.
COMPUTERS
In addition to the computers in the library, there are three computers in the residents' lounge.
OVERALL IMPRESSION
Although probably not right around the corner from your home, the commute to RCH is not a
major burden. Many students even ride their bike to the hospital from downtown Vancouver
regularly. Becoming familiar with the hospital is also not a challenge due to its size and simple
layout. There are generally fewer students per rotation at RCH than at the larger sites resulting in
more one-on-one time with your residents and attending. The student amenities, including
comfortable call rooms and free food send a clear message that RCH is welcoming to, and
supportive of, its students and residents. For this reason, the atmosphere at RCH tends to be more
relaxed. Residents are more at ease and staff are more willing to take the time to teach.
Regardless of which rotation you complete at RCH, you will likely have a very positive
experience.
88
RGH: Richmond General

Hospital
Written by Jessica Fong, MD 2013
Edited by Jackson Chu, MD 2014
Richmond General Hospital is a smaller community hospital which gives it both advantages and
disadvantages. One of the major advantages of working at RGH is the direct contact with staff
physicians. For specialties like surgery and obs/gyne, this means direct access to the patient as
opposed to peering over the shoulder of residents and fellows. Another advantage is that there are
fewer medical students in each rotation. In the emergency rotation, there is only one student! If
you are lucky enough to be that student, you will always have priority access to wounds that need
suturing, code blues and other bread and butter cases. Because of the one-on-one time with staff
and the increased responsibilities at RGH, this is a great hospital to experience a specialty that
you are interested in pursuing. Not only do you get a chance to learn and show off your stuff, but
the possibility of a great reference letter is much better here than at other hospitals! Of course,
this also means that there is no chance to hide in the shadows so when doing a rotation at RGH,
be sure to be on your game!
GETTING THERE
Richmond Hospital is located at the intersection of Gilbert Rd and Westminster Hwy. It is
accessible by public transit or by car.
If you are driving to RGH, head south on Granville and over the Arthur Lange Bridge. Of
course, there are multiple other routes to the Arthur Lange Bridge too! From the bridge, take Russ
Baker Way/ No. 2 Road towards Richmond and hang a left on Gilbert Road. The hospital is on
Gilbert Road just past Westminster Highway (on the left!). From VGH, expect the trip to take
about 30 minutes without traffic. When you arrive at RGH, there is generally plenty of parking
available in a multi-level parkade. With a staff parking pass, which can be obtained from the site
administrator, students can park for $6.50/day. Monthly parking passes are available but there is
no staff rate for these passes. An alternative to parking in the hospital lot is non-restricted parking
on Azure Road, approximately 5-7 minutes from the hospital.
No car? If you can find your way to a Canada Line station, taking transit to RGH is easy. Simply
take the Canada Line to the Richmond-Brighouse station. From there, you can either walk (about
1.2 km or 15 min) or take a short bus ride (5 min) via the #401-One Road or #407-Gilbert
directly to the hospital.
Cycling to RGH? There is a bike cage is located on the ground floor of the multiple storey
parkade. You can access the parkade using a VGH ID specially coded by the Parking and
Security Office. Cant find the office? Head down the same hallway used to access the OR locker
rooms. It is past the lockers. Or, better yet, ask at the info desk!
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STORING YOUR STUFF

Lockers can be found adjacent to the call rooms and on 4N. Students on surgical rotations can
use lockers located in the OR and those on their ER rotation will be provided with a locker in
emerg. Regardless of which locker you occupy, bring your own lock!
KEEPING CLEAN
One thing that all patients that present to emerg have in common is that they dont shower
first...resulting in some very interesting odours. There is no excuse for you to forgo showering
however as there are plenty of showers available. They can be found by the call rooms in the
Rotunda (beside the gym) or on 4N.
CALL ROOMS
There are 3 call rooms in the Rotunda and 3 more on 4N. To access the rooms, all that you need
is your VCH ID badge. Students generally prefer the rooms located on 4N. It is fairly easy to get a
room as it is really only the surgery and Obs/Gyne medical students who intend to use
them...and only the Obs/Gyne students that do use them!
THE LOUNGE
If you have the luxury of getting a break, there is a doctors lounge located beside the library and
a separate lounge in emerg for ER docs, nurses and students. Computers and a printer are
available for your use in the doctors lounge. Both spaces have access to their own microwave and
fridge.
THE CAFETERIA
Hungry? Dont raid the ER fridge - that food is for patients! The cafeteria is located on the second
floor. Serving hours for hot meals are fairly limited but there are sandwiches and snacks available
all day. The hours of operation are between 7:00am to 6:30pm, 7 days a week.
COFFEE!
Coffee can be found in the cafeteria on the second floor or at the Starbucks located in the main
lobby. IV caffeine is not yet available at this site. Starbucks is open from 7:00am to 6:00pm on
weekdays and from 10:00am to 6:00pm on weekends.
GOOD EATS CLOSE BY

Richmond Centre, a short distance by foot from the hospital has wide variety of options in its
food court in addition to a grocery store. If fast food isnt your thing, there are also a variety of
restaurants along Westminster Hwy located within walking distance from the hospital.
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THE LIBRARY
The library can be found on the main floor. If you need to access the library after hours, head
around the back through the corridor where the doctors lounge is located (with ID badge for
access).
COMPUTERS
Computers are available in the library but require a login, which will be arranged for you by the
site administrator. The computers in the doctors lounge do not require a login. There is also wifi
(ubcsecure) available in most parts of the building.
OVERALL IMPRESSION
Being a smaller hospital, RGH is not only easier to navigate than the larger hospitals but is also
easier to get to know the other health care providers that work with and around you. The
commute is very reasonable and shouldnt detract from your experience at RGH. Because of its
size, however, the patient volume is reduced and you may not see as many cases as you might at
VGH or SPH. This is especially true for Obs/Gyne where deliveries occur much less frequently
than at BCWH. In addition, RGH is not a trauma center which limits your experience in both
surgical specialties and emergency. Altogether, however, the hands-on experience that you will get
at RGH is unparalleled by the experiences at larger hospitals and you will find the time that you
spend there very rewarding.
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SMH: Surrey Memorial Hospital

Surrey Memorial Hospital is a busy tertiary care center that is part of the Fraser Health Authority
service area. It sees a wide variety of pathologies, and its average patient population is younger
than other hospital sites. Coupled with the fact that SMH has the 2nd highest number of
deliveries in the province (after BC Womens), this means that its a great site to experience
pediatrics. This is especially true for students who wish to see the bread and butter of pediatrics,
or who are more family practice inclined, and dont feel experiencing rare pediatric diseases is an
essential part of their learning. Surrey Memorial Hospital is an available site option for:pediatrics - psychiatry emergency.
GETTING THERE
SMH is located in central Surrey at the intersection of King George Boulevard and 96th avenue.
It is easily accessible by public transit, as it is only a 10-minute walk south from King George
Skytrain Station. Yes, one COULD catch a bus from the skytrain to the hospital, but that actually
takes longer than the walk, and would only reflect laziness. In terms of driving to the hospital, it
is best accessed from most of Greater Vancouver (except Richmond and New Westminster) by
following the Trans-Canada highway over the Port Mann Bridge, taking exit 48 at 152nd Street,
and proceeding south before making a right at 96th Avenue.
PARKING
Parking options include:
$51.00/month for a staff parking pass in the main parkade for daily drivers
$5.75/day with a free staff parking hanger for intermittent drivers
Free residential parking around the area, some for residents only, others with a 2 hour
max, for very broke (or cheap/thrifty) drivers
SMH Map can be found here:

http://www.fraserhealth.ca/media/SMHMapDirector y.pdf
STORING YOUR STUFF

Students can take any available locker by the call room area on the 2nd floor of Area F (orange
line). These come in full or half height, metal or wood, and clean or not-so clean. Choose wisely.
Beyond this area, the only other place to store stuff would be your car, or under the nursing
station tables of the ward youre on (nurses may not always like this, so definitely ask
beforehand!)
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KEEPING CLEAN
There are brand new showers by the call rooms (logical enough). There are towels by the
showers. There is a laundry bin by the towels. Um...that is all.
CALL ROOMS
As noted above, call rooms are on the 2nd floor of Area F (orange line). There will be a
designated call room for medical students, and within it theres a single-sized bed with a memory
foam mattress! Arguably the comfiest call room bed encountered among the major hospitals.
Beyond that though, there is little else in the room other than a bedside table. The rooms can get
cold during winters, so its best to turn on the old radiator in the room a bit for heat. In the
morning, dont forget to hang the foam doorhanger that says Please clean room on the outside
handle of the door! Otherwise whoevers on call after you will have to change their own
sheets...not fun.
THE LOUNGE
Like everything else, the lounge is also located by the call rooms on Area F 2nd floor. This
lounge, although small, is brand new, very cozy, and has 2 comfy couches, a new 40+ inch wallmounted flat screen tv, a computer, a small dining table, microwave, fridge, eating utensils, and
hot chocolate/coffee in the cupboards! Much of ones downtime when on call can be spent here
eating, watching tv, and using the computer at the same time. As SMH only has a few medical
students and residents around, most of the time the lounge will be free for just the on-call student
to enjoy!
THE CAFETERIA
The cafeteria is located in the corner of Area B (orange line). Standard hospital fare, but at
relatively reasonable prices. The cafeteria, like many others in hospitals, are always closed earlier
than youd think would make sense or be reasonable, but theres always the vending machines
around. The cafeteria actually has some prepackaged microwavable meals, such as tv dinners and
burritos, along with a good selection of snacks, drinks, and ice cream in their vending machines.
This helps when its late night on call to still find something decent to microwave in the lounge
and eat!
COFFEE!
Onsite caffeine includes the Kidz Cafe (main lobby, south building), a coffee stop (main lobby,
north building), and the coffee machine in the lounge. Offsite coffee is available at the Tim
Hortons across the street (at the corner of King George Boulevard and 96th Avenue).
Unfortunately the nearest Starbucks is a 10+ minute walk away.
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GOOD EATS CLOSE BY

In addition to the Tim Hortons, there is also a Dairy Queen Brasserie further down King George
Boulevard (which has burgers and hot food, albeit at a marked up price vs other locations).
Nearby restaurant fare includes a Knight and Day and Swiss Chalet heading towards the skytrain
station, and even closer, the China Village Wonton House (questionable quality of food as it
always looks completely empty...
THE LIBRARY & COMPUTERS

Surprise surprise, the library is located where else but by the call rooms on 2nd floor Area F
(orange line), rounding out the central hub of anything and everything that the med student
could need in one place. Dont have high expectations of this library, as its not very sizeable, but
does have 2 computers for use, an all-you-can-use printer, some tables to read at, and a smattering
of various books and references. Other than these computers, the only other choices are the
computers on the wards or the one in the lounge. Though small, the library does provide a quiet
study space as few people use it. An alternative study space is the videoconference room down
the hall, which has more comfy chairs and better air conditioning (other areas of that floor can
get stuffy).
OVERALL IMPRESSION
Surrey Memorial Hospital is by no means a humongous hospital, but it is precisely this fact that
makes it a likeable site to be at. Everything in the hospital is within 5 minutes walking distance,
which is a huge boon when it comes time to rush to the delivery suites in the middle of the night
during pediatrics call. It also means within the first day of walking around, you wont ever be lost
again. Also, as there are essentially only 2 floors that are relevant in any given area of the
hospital, it means one doesnt have to wait forever for elevators that never come or which are jam
packed with people. The call rooms and lounge are essentially brand new, very comfy and well
furbished, and further improvements are still continuing to be made to those spaces. It is very
much accessible by public transit, and also has very cheap monthly parking available, making any
form of commuting simple enough, even if some find it a bit far.
The pediatrics experience is very commendable here, and the ward and staff are both very
welcoming and nice. Emergency also offers a busy, but balanced experience here, although one
may be taken aback by the sheer number of patients lying in beds placed in the hallway.
Psychiatry also offers a pleasant experience with a diverse balance of patients, both adult and
pediatric. Overall, if you desire a change of pace from the large, overwhelming size of the central
tertiary hospitals, SMH presents a great opportunity to be somewhere new and enjoy a great care
facility!
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SPH: St. Paul's Hospital

Written by Benjamin Jong, MD 2013
Edited by Ben Tuyp, MD 2014
St. Paulss Hospital is a large primary care hospital serving the unique downtown Vancouver
population. Because of its size and patient volume, you will be exposed to a wide variety of
important cases from trauma to heart failure to meningitis depending on your rotation. However,
as a result of its diverse population, these cases are also often complicated by comorbidities such
as alcoholism or drug abuse. As such infections and other diseases that often result from IVDU,
poor hygiene or alcohol abuse must also be addressed. In addition, involving social work in the
care of SPH patients is also necessary. On most rotations you will part of a large team including
other medical students, residents and possibly fellows. As a result, your opportunity to interact
directly with staff may be reduced. Because of its patient volume, you can expect to busy at SPH.
Popular rotations at SPH include Internal Medicine, Orthopaedics, Anaesthesia and possibly
Psychiatry.
GETTING THERE
St. Pauls Hospital is located on the West side of Burrard Street, between Davie and Comox. If
driving, allow for traffic, especially in the morning and afternoon rush hours. The hospitals
underground parking lot is $5.75 per day with your VCH ID, but it fills up early. Aside from this,
youll be spending $15-$30 to leave your car for the day.
Using transit is a very effect means of getting to SPH. The hospital is located 1km South of the
Burrard Skytrain station and 1km Southwest of the Canada Line City Centre station. The #2,
22, 32, 44, and N22 buses all travel down Burrard, and transit along Granville is only 4 blocks
away.
If you are travelling between other hospitals in Vancouver, the InterHospital Shuttle provides
great service. This dedicated shuttle runs 7 days a week, leaving SPH every 30 minutes from 7:05
to 4:35 en route to BCCA, VGH, GF Strong and Childrens. In the other direction, arrivals at
SPH are every 30 minutes from 7:33 to 8:03. Schedule found at
www.phsa.ca/NR/rdonlyres/92CA01DA-FDC0-49B1-955F2C8617FF718B/0/ShuttleSchedule.doc .
Allow for extra time however as the system gets busy during the day, and there may not always be
room for more passengers.
If you live in or close to downtown Vancouver, cycling to SPH might be the most efficient
method of transportation. Bike lanes on Hornby and Burrard make SPH an easy destination. A
bike cage is found in the parkade off Burrard, accessible via a Providence ID which can be
obtained from Security on the 4th floor of the Burrard building. There are many open bike racks
on street level as well.
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STORING YOUR STUFF

Lockers for students are available in the call room area (Burrard 6). Just be careful not to use a
locker already assigned to another MSI or resident. Students rotating through Internal Medicine
also have access to lockers on the 7th floor of the Providence building, and those rotating through
Emergency Medicine are provided lockers beside the ED on a first-come, first-served basis.
Students are often not assigned a locker for short rotations. However, for many short rotations
lockers may not be necessary, as you may be based out of a nursing station or office that is
sufficiently secure.
KEEPING CLEAN/CALL ROOMS/LOUNGE

In contrast to the rest of SPH, the call rooms and student lounge is new and very comfortable.
Call rooms, showers, a microwave, computers, a television and a lounge area are all found on
Burrard 6. After walking in the main entrance to the Burrard building, go left and take the first
elevator on your right to the 6th floor. More showers are found within the locker rooms on
Burrard 4, just across from the eating disorder clinic. A Providence ID is required to access both
the 6th floor lounge and the 4th floor lockers. You will need to have your badge reactivated after
six months of inactivity, so bring it to security in the ED as necessary.
THE CAFETERIA
The cafeteria has a decent salad bar but otherwise serves basic fare such as burgers, pizza,
sandwiches and a daily special. It is not well reviewed by most students. Thankfully, with so
many outside options immediately available, it can be easily avoided.
COFFEE!
For a quick fix, coffee is sold just inside the main entrance of SPH and in the cafeteria. Outside
of the hospital, decent coffee can be found at Beyond Caf which is located on the ground floor
of the Century Plaza Hotel. Theres also a Blenz across the street, a Tim Hortons in the gas
station south of the hospital, a Starbucks at Davie and Thurlow, and many other places nearby.
GOOD EATS CLOSE BY

You are in Downtown Vancouver so good food is never far away! A good idea is to head West on
Davie street. There, you can choose from Kadoya (sushi), Thai Basil, Banana Leaf (Southeast
Asian), Veras Burgers, Subway (24hrs), Mucho Burrito (East on Davie) and others. If bringing a
lunch, the call room has a fridge and microwave that are available for students to use.
THE LIBRARY
This is located on floor 1 of the Providence Building. Just follow the signs.
COMPUTERS
Computers are available in the call-room area of Burrard 6 and in the library on Providence 1.
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OVERALL IMPRESSION
SPH is a large hospital composed of two main buildings: Burrard and Providence. The two
buildings are connected on floors 1-3 by an indoor corridor and on the fourth floor by an outdoor
walkway. The layout not only confuses patients but also students! With time, however, you will
learn to find your way around. An older building, SPH acts its age as the wards are often
cramped with multiple patients in the room and often others in the hallway. In addition, few of
the elevators are in operation at one time and you are therefore advised to take the stairs! Despite
its downtown location, commuting to SPH can be difficult as a result of traffic, lack of parking or
crowded transit. The staff physicians are knowledgeable and a pleasure to work with as long as
you can keep pace with the demanding patient load. Because of both its physicians and patient
population, SPH is a prime site to learn through real cases as opposed to through books and I
would encourage you to spend some time there!
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VGH: Vancouver General

Hospital
Written by Benjamin Jong, MD 2013
Edited by Charlie Zhang and Harman Parhar, MD 2014
Vancouver General Hospital is one of two tertiary care hospitals in the VFMP program. Because
of its size and patient population, not only does it offer all rotations (except paediatrics) at this
site but it also offers the possibility of seeing a wide variety of important cases. You can expect to
work with larger teams at VGH resulting in less chance of one-on-one time with your resident or
attending. Popular rotations at VGH include emerg, due to the exposure to trauma cases, and the
surgical sub-specialties. General surgery at VGH has been given poor reviews in the past largely
because of the competition for OR experience with other medical students, residents and fellows.
That being said, however, your experience in clerkship is what you make of it. Through their
enthusiasm and perseverance, those students that are very interested in surgery are often able to
create exceptional experiences at VGH for themselves. The consensus on Internal Medicine is
mixed. You can expect to work hard at VGH carrying a large number of patients and working
most of the night on call shifts. However, you will also likely see many bread and butter cases
ultimately improving your knowledge of, and skills in, internal medicine.
GETTING THERE
VGH is located centrally and unless you are not from the VFMP program, or slept through all of
first and second year, you should know where it is! There are multiple methods of commuting to
VGH.
Although getting to VGH by car is not a challenge, parking in close proximity to the VGH is
expensive. Flashing your ID badge at the parkade at 12th avenue and Laurel street will grant you
access on arrival and ensure you pay no more than $8.50 when you exit. Although there is also
free parking between 15th and 20th these spots are quickly filled making it difficult to get one
unless you arrive before 0730. I would not recommend parking in the resident only or two hour
area for the day as students have known to be ticketed and towed.
Second only to arriving by ambulance or helicopter, transit is a fantastic method of commuting.
Several bus routes run by VGH. Many students rely on the #9, #99, or #17. In addition to the
bus, the Broadway/City Hall stop on the Canada Line is located at Broadway and Cambie street,
a 5-10 minute walk from VGH.
If you prefer to pedal your way around, a bike cage is available in the Diamond Parkade. In order
to access the bike cage and the adjoining locker rooms, you will need your VGH ID card
activated by security. You can also store your bike at the Medical Student Alumni Center (located
on the corner of Ash Street and West 12th Avenue) which is a 3 minute walk from VGH.
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STORING YOUR STUFF

Storage options depend on your rotation. For longer rotations such as general surgery and
internal medicine, lockers are generally provided (although they may be shared). For smaller
rotations, you may be assigned a locker by the department administrator. Be sure to check your
reporting instructions and orientation documents to find out about the storage that you will be
provided. If there is no information, a friendly email to the department administrator or program
assistant is warranted. If you do not receive a locker, you will have to carry your things around
with you. On surgical rotations, youre safe to leave your clothes on a hook in the locker room
and change into scrubs. Just be sure to take your valuables with you. The Medical Student
Alumni Center is located very close to VGH is a good option to store heavy books or bicycle
helmets.
KEEPING CLEAN
The call rooms on the second floor of the Centennial Pavilion have a shower available. Towels
are also provided. On a busy call shift, do your colleagues, your patients and yourself a favour
and use it!
CALL ROOMS
The call rooms are located on the second floor of the Centennial Pavilion. When you start your
rotation and there is in-house call, the program administrator should provide you with the code
for the services MSI call room. The rooms lack luxury to say the least but you likely will not be
using them anyway!
THE LOUNGE
Not busy? Ask your attending or resident what you can do. Still not busy and need a place to
relax (or recover)? There are a few options here. Located near the call rooms there is a doctors
lounge with a refrigerator and other amenities. In addition to this space there is also an OR
lounge (used by students primarily when on a surgical rotation) which also has a refrigerator and
microwaves. The OR lounge is located on the same floor as the cafeteria and the OR (surprise,
surprise). It can also be accessed from the OR itself. Getting to the lounge is easy but rather
complicated to describe in text. When you embark on a surgical rotation, its best is to ask a
resident or another student how to get there.
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THE CAFETERIA
The cafeteria at VGH is commendable for the fact that it is convenient for on-the-go students.
Nonetheless, it is somewhat expensive for the food you may get. Most food items sold at the
cafeteria are decent, as they are safe and edible. It is advisable, though, to forgo the pizza as its
over-priced, rather unsatisfying, and may cause you some digestive discomfort. So, use the
cafeteria when you must, but be sure to check out Broadway Street for some delectable cuisines.
If you have a longer break (>30 minutes), theres a nice food court within City Square shopping
mall, which is located on the corner of Ash and 12th. It is about a 5-7 minute walk from VGH.
There are also many nice restaurants on Broadway which are not much more expensive than the
cafeteria at VGH but have much better quality.
COFFEE!
For the caffeine fanatics, coffee is available at several locations in and around VGH. You can get
your fix from: the cafeteria (not bad, but not great), Caf Ami on the first floor between
Centennial Pavilion and JP Tower (has good coffee, munchies and sandwiches), Starbucks and
Zookaz at Diamond, Tim Hortons (Broadway) which is open 24/7, and numerous other options
along Broadway Street (e.g. Blenz, Caf Artigiano).
GOOD EATS CLOSE BY

Take your pick along Broadway. Some notable food places include:
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Banana Leaf
Tim Hortons/Wendys (24/7)
Quiznos
Subway
Saravanaa Bhavan (South Indian)
Thai 24/7 (near 7-11 on corner of Oak and Broadway)
Indian place with $5 lunch special (near TD Bank and bus stop on Broadway)
Donair Spot
Cactus Club
Sha Lin Noodle House
Food court in City Square shopping mall
Multiple great sushi places nearby
THE LIBRARY
Probably one located somewhere in VGH, but youre better off going to the library at Diamond.
You can also study at the MSAC. There are computers and desks available upstairs and
downstairs and not many people use it during the school year. During the day most people are in
class or on rotation, and at night it is completely empty. Times to avoid the MSAC (when you are
looking for a quiet space) are in the afternoon/evenings because events are held at this time year
round.
COMPUTERS
To check on ward stuff/patients labs, you can use almost any computer at the nursing stations in
the JP Tower. To check your email or other non-work related things, using a computer in
Diamond is probably the most guilt-free option. There are other computers around VGH, if you
see no one around, go for it, but keep in mind that people need to work. Avoid using nursing
station computers for non-ward/patient related things during busy times (i.e., morning rounds,
afternoon rounds). There are also some nice computers in the downstairs lounge at the MSAC.
OVERALL IMPRESSION
VGH is a large hospital but navigating the building is usually not a challenge and for each
rotation you will be stationed in a specific location. If you were able to get to PBL and lectures
on time in 2nd year, commuting to VGH should be no more challenging. Then again, 6am rounds
can be a different animal. The health care team at VGH including physicians, residents, nursing
staff and others are friendly and a pleasure to work with so long as you show that you are a
dedicated, keen and respectful student. Being one of the busiest sites in VFMP, I recommend that
you spend at least one rotation there for the variety of exposures and to learn how to excel under
significant pressure.
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SITES: SMP
KGH: Kelowna General Hospital ...................................... 103
VJH: Ver non Jubilee Hospital.......................................... 105
102
The CLERKSHIP GUIDE | Sites: SMP
KGH: Kelowna General Hospital

Written by Aaron Gropper, MD 2013
GETTING THERE
If you drive, you can park in the lot for $5 a day. However, parking is very limited. There are also
a few bike racks, but no bike cage.
STORING YOUR STUFF

Lockers can be found in the same room as the shower. This is definitely not ideal because if
someone is in the shower, you can't access your locker!
KEEPING CLEAN
Showers can be found in the same room as the lockers. OK, I know I just reversed the sentence
above. But KGH is a small hospital youll find your way. I guarantee it!
CALL ROOMS
There are no call rooms. Why? Because there is no call! Although surgery has overnight call, that
is done from home.
THE LOUNGE
There is a room that they claim is the student lounge but is really just a PBL style room that is
used for rounds and meetings. There is no fridge or microwave but it does have a computer which
I suppose can double as a microwave if you leave your food on top of it long enough (kidding of
course).
THE CAFETERIA
The cafeteria is on the main floor of the hospital. Small and not very exciting - serving your
basics like soups, sandwiches, a daily special and a salad bar. What were you expecting?
COFFEE!
There is a coffee shop on the main floor. Otherwise, coffee shops exist 15-20 minutes away by
foot.
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GOOD EATS CLOSE BY

Pandosy village is about a 5 minute drive or 20 minute walk away and is the closest place for
other food options. There is a coffee shop, a pub, subway and a few restaurants. Downtown
Kelowna is a 5-10 minute drive north of the hospital. There you can find any fast food chain you
crave and a wide variety of other options!
THE LIBRARY
The library is in the Clinical Academic Campus and has lots of computers.
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VJH: Ver non Jubilee Hospital

Written by Aaron Gropper, MD 2013
GETTING THERE
Vernon is a small city and it is possible to live close enough to the hospital to walk every
morning.
If you are driving, parking can be difficult if you don't come early enough but it is very
inexpensive: $2/day. There is also street parking a short distance from the hospital.
The transit schedule is less than ideal, but there are some routes that pass by the hospital. All
other routes take you downtown and the hospital is a 10 minute walk from downtown. If you
prefer to ride your bike, there is no bike cage, but there are some bike racks in front of the ER.
STORING YOUR STUFF

Students are provided with dedicated lockers in the hospital. There are also lockers in the OR
change room.
KEEPING CLEAN
Showers are also available both in the call rooms and in the OR change room.
CALL ROOMS
There are three call rooms in the new tower: one at the back of ER, one on the fourth floor
(maternity/children's ward), and one on the fifth floor (ICU). There is also a student call room in
the old tower on the 4th floor.
THE LOUNGE
There is no dedicated medical student lounge, but there is a medical staff lounge on the 3rd floor
of the new tower. It's along the same corridor as the OR change rooms. There are three
computers, a TV, couches, a fridge/freezer, a microwave, and tables. There are also free cookies
and coffee daily!
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THE CAFETERIA
The cafeteria is located in the basement of the old tower. It has odd hours though. It is open for
breakfast and lunch, but closes shortly after 1:00pm. It is also only open on weekdays. The prices
are very reasonable and the quality of the food is pretty good. There is also a cafe on the main
floor of the old tower that is open from 06:00 to 19:00 every day (I think it closes an hour earlier
on the weekend). It has food, drinks, and snacks, but tends to be pricier than the cafeteria.
There is a cafe on the main floor of the hospital (Crack Pot). There's another location of the
Crack Pot downtown.
COFFEE!
The nearest chain coffee shop would be Starbucks at the bottom of the hospital hill, which is
about 500m from the hospital.
GOOD EATS CLOSE BY

There are many chain restaurants at the bottom of the hospital hill (Wraps, Subway, Earls). If
you're looking to get away from chains, your best bet is along the main strip of downtown, about
4-5 blocks further north from the chain restaurants. There, you can find a good mix of Indian,
Asian, Greek, Mediterranean food.
THE LIBRARY
The library is in the basement of the old tower, near the cafeteria. It has a good collection of
books, including all of the recommended/required books for clerkship.
COMPUTERS
There are 5 computers in the library. Although access to the computers in the library is very
good, cell phone reception in the library is not great at all.
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SITES: IMP
Campbell River Hospital................................................. 108
Cowichan River Hospital................................................. 109
LMH: Lady Minto Hospital ............................................. 110
SJH: St. Joseph's Hospital............................................... 111
VGH: Victoria General Hospital ....................................... 112
WCGH: West Coast General Hospital (Por t Alber ni) ..... . . . . . .113
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The CLERKSHIP GUIDE | Sites: IMP
Campbell River Hospital

Written by Graeme Bock and Edmond Li, MD 2014
GETTING THERE
Campbell River Hospital is located in the center of the town but this does not necessarily mean
that you will be living close by. For a place to stay, there are a few postings on Med housing and
there are some inns near the hospital. Because your commute to the hospital may be outside of
walking distance, a car is strongly recommended. Although parking at the hospital is not free,
there is plenty of free parking on the street nearby.
STORING YOUR STUFF

Although lockers are available in the hospital, there may not be any for students to use so be
prepared to go without one.
CALL ROOMS/LOUNGE
There is no student lounge or student call rooms but students are free to use the staff lounge
which has a few computers, books, a microwave, and a coffee machine.
FOOD!
There is a cafeteria in the hospital with limited options and a small coffee shop outside the
hospital. There are also some grocery stores, a bakery, a 7/11, and some restaurants within a 10
minute walk from CRH.
108
Cowichan River Hospital

GETTING THERE
Cowichan District Hospital is located a moderate distance from the town of Duncan and both
driving and cycling are good options for transportation.
STUDENT AREA
Showers, study space with a library, kitchen space, lockers, and call rooms are available in the
student area.
FOOD!
There is a cafeteria in the hospital and a 7/11 nearby. The town of Duncan is a little ways away
but has a variety of options if you find time for a good walk or have access to a car.
109
LMH: Lady Minto Hospital

GETTING THERE
Lady Minto Hospital is a 2 minute drive or 10 minute walk from the town centre. To find a place
to stay that is close by, students recommend posting an ad on the Salt Spring Exchange (their
version of Craigslist).
LIVING THERE
There is no cafeteria but the town is close enough to find food and coffee. In the hospital, there is
a small lounge with a basic kitchen. There are also showers at the nurses station and outside the
OR.
Memorable Moments
Travelling via Helicopter to remote First Nations
communities during my rural rotation was unforgettable. To
be able to experience how health care is delivered to these
unique patients was humbling and eye-opening. It reminded
me that although there is glamour in travelling overseas to
serve third-world populations, we have a very near to third
world population just hours from where we live, study and
play.
110
SJH: St. Joseph's Hospital

GETTING THERE
St. Josephs General Hospital is a 10 minute walk from downtown Comox. A car is useful, but a
bike will do if you stay in Comox. If you drive, parking is $30 per month and you can use a
VIHA parking pass. The transit system is not recommended as it isnt very regular.
LIVING THERE
Theres no student lounge but the staff lounge has a microwave and fridges. The surgical and
maternity wards have showers and lockers. The call rooms are located at the maternity wards.
FOOD!
The nearest coffee shop and restaurant is downtown, a 10 minute walk from the hospital
111
VGH: Victoria General Hospital

GETTING THERE
Victoria General Hospital is located along the Trans-Canada Highway approximately 20-25
minutes west of UVic. Because of the distance, a car is highly recommended for transportation.
However, cycling (35 minutes from UVic) and transit (1hr) work if you have the time. Parking at
UVic is easy if you obtain a weekly pass as this allows you to you to park anywhere including the
doctors spots.
STORING YOUR STUFF

Lockers are available for student storage but third years are encouraged to share lockers.
CALL ROOMS
Call rooms can be found in the IMP area adjacent to the ER/physiotherapy area on the ground
level.
THE LOUNGE
There is a student lounge with amenities including a computer, fridge, microwave, sink and
couch. The couch is convertible to a sleeping cot.
FOOD!
Theres a cafeteria in the hospital with good lunch options but Tim Hortons has better hours.
There are also a few coffee shops and restaurants along Island Highway which can be accessed by
travelling south along Helmcken Road.
112
WCGH: West Coast General

Hospital (Por t Alber ni)
Edited by Christine Kang, MD 2014
GETTING THERE
West Coast General Hospital is a 5 minute drive from downtown Port Alberni and about a 5-7
minute drive from the doctors clinics. Parking is free and having a car is strongly recommended
because it will allow you to get to the hospital quickly when called. While cycling is a good
alternative to driving, transit is not due to its questionable reliability.
STORING YOUR STUFF

There are no lockers for students, so be sure to pack light. Of course, if you forget something,
home is never far away! If you are in the OR, you can usually use a relief locker in the change
rooms (no lock).
CALL ROOMS
There is a call room located adjacent to the doctors lounge.
THE LOUNGE/LIBRARY
The doctors lounge is available for use by medical students, and it has a fridge, microwave,
couches, a TV, and computers. There is a library located next to the doctors lounge.
FOOD!
There is a cafeteria in the hospital but the town of Port Alberni is very close and has a much
wider variety of options. There is a McDonalds, KFC, Subway, Dominos, and more within a 2minute drive.
113
ROTATIONS
Inter nal Medicine........................................................... 115
Pediatrics...................................................................... 126
Surger y......................................................................... 138
Emergency.................................................................... 148
Anesthesia.................................................................... 158
Or thopedics................................................................... 165
Obstetrics and Gynaecology ............................................. 171
Ophthalmolog y.............................................................. 183
Dermatolog y................................................................. 189
Psychiatr y..................................................................... 194
Third Year Elective......................................................... 203
114
The CLERKSHIP GUIDE | Rotations
Inter nal Medicine

Edited by Lawrence Haiducu and Jackson Chu, MD 2014
THE BIG PICTURE: INTRODUCTION

Internal Medicine is one of the Big 3 rotations and is comprised of 8 weeks of hospital based
clinical service. Within these 8 weeks, activities include inpatient care, outpatient consultation
clinics, as well as overnight call shifts that occur on a 1 in 5 schedule during which students will
complete new patient consults. Students at the major hospital sites (VGH, SPH, RCH) will be
working on care teams consisting of 2-3 medical clerks, 1-2 IMG residents, 1-2 internal medicine
junior residents (R1), and a senior internal medicine resident (R2 or R3), which will be
supervised by an attending doctor at the hospital.
Although renowned to be difficult and tiring, it is potentially one of the most rewarding rotations
that students experience throughout the year. As described by one attending, students will never
have as much responsibility for direct patient care placed upon them as they will receive during
the internal medicine rotation. This is due to the fact that the student may act as the primary
care coordinator, with the supervising members of the team relying on your observations. This
responsibility is essential in developing skills as thorough observers and critical thinkers, and
should be embraced to gain the most benefit and enjoyment!
THE CLINICS: OUTPATIENT WEEKS

Students at all urban sites will spend 2 of their 8 weeks on the internal medicine outpatient
service in order to increase their breadth of experience. This generally involves working in a
clinic setting alongside an internal medicine sub-specialist, such as cardiology, gastroenterology,
rheumatology, endocrinology, nephrology, hematology, and various other fields. There will also
be placements with general internists, who either have areas of special interest such as eating
disorders, hypertension, pre-surgical health evaluation, etc., or those who manage complex multisystem illness patients referred by family physicians for ongoing care.
Students will be responsible for seeing both new patients and follow-ups, gathering data,
presenting the information to the general internist theyre working with, and collaborating
together to develop a management strategy for the patient. There is also an expectation for
students to complete dictations for patients they see in clinic, and have these reviewed by their
attending. Along with clinic experience, there will also be individualized teaching sessions
relevant to outpatient consultation services presented by the supervising internist.
115
During the outpatient weeks, students will not partake in most of the inpatient service duties.
Depending on schedules, there are some opportunities to attend noon rounds as per normal, but
there is no expectation for outpatient students to be at morning report/rounds, or to carry any
assigned inpatients. As only 1 student from each team will be on the outpatient service at a time,
the remaining members of the team will take over for the management of the missing students
patients. With the exception of weekends (Friday inclusive), outpatient service students are
exempt from overnight call. This provides a valuable opportunity for students to have extra
available study time to consolidate their knowledge. These 2 weeks are essentially a call-free
vacation opportunity when students should either be reading ahead to increase their knowledge,
seeing the time as a break in the middle of internal, or using it as some much needed cramming
time 2 weeks before the exams. Use it wisely!
Memorable Moments
Internal medicine was my very first rotation of third year, and I found it
rather intimidating. On one of my call shifts, I was asked to see a
patient in emergency who had a lot of co-morbidities and was
complaining of shortness of breath. Having already been seen by the
emergency physician, the cardiac team, and my internal medicine
attending, and the consensus was: a COPD exacerbation, but I was sent
in to do my (redundant, I thought) history and physical anyway. The
patient told me the story, which included some chest discomfort, and
after I was finished my exam, I looked up the labs. The emergency
physician had ordered a troponin, of course, and I noticed that it was
ever so slightly elevated about 8 hours ago. No follow-up troponin
was in the system. I turned to the resident sitting next to me. I know
this patient seems to be having a COPD exacerbation, but the troponin
is a little elevated and there was no follow-up value. Shouldnt we order
a second troponin just in case? The resident looked through the
information on the patient and agreed that a follow-up troponin was
probably a good idea, so I put in the order.
I checked back later to see if the result was in, and it was. The troponin
was 23. Yes, you read that right. TWENTY-THREE. Given that a
normal troponin is less than 0.05, 23 is a really, really high number. I
had just caught an NSTEMI. Not bad for a newbie. Just goes to show
that sometimes, the fresh eyes of a medical student really can make a
difference!
Life Outside of Medicine

Despite popular belief, there is life
outside of internal medicine. You just
have to make time for it. The most
important day during internal medicine
for me was post-call day. On the day of
call, I would try to find some time to nap
during the afternoon when it was not
busy. Overnight, I generally slept very
little and woke early to round on
patients before the morning meeting.
This allowed me to often leave before
noon. After leaving the hospital, I would
have a nice lunch, a nap and a free
evening! These evenings often included a
movie, catching up with friends or
maybe a jog around Vancouver. A lot of
prep for a few hours of relaxation but it
is certainly worth it!
THE ITINERARY: STUDENT SCHEDULES

The schedule varies from site to site, but students will work Monday to Friday plus call shifts. A
typical inpatient care day will begin with morning rounds at 8am, which comprises of a brief
review of the yesterdays status of patients under the care team and the formulation of care plans
for the day. St. Pauls Hospital students start their mornings with case-based teaching rounds
presented by internal medicine residents and led by the chief resident, and may or may not meet
with their team during the morning depending on the senior resident.
116
Students will then see their assigned patients (typically 2-3 at any point in time), check on lab
results and other completed investigations from the prior day, and write a comprehensive progress
note in the charts. If any further investigations (ex. chest x-ray, ECG, additional bloodwork, etc)
is required in a timely fashion, this can be ordered as well after discussion with the senior
resident. Following the morning activities, many teams will meet again before noon for
discussion rounds to report on the current condition of patients, receive teaching and instructions
regarding the next step of the patient care plan, and what should be expected or will require
follow-up on during the afternoon.
Lunch time usually consists of noon time interspecialty rounds, in which students are expected to
attend the presentation delivered by a variety of doctors in different fields on selected topics.
These sessions provide a great opportunity for students to sit and get a break from the morning
hecticness, gain new knowledge, and luckily, eat the free lunch that is often provided at these
rounds!
The afternoon varies depending on the day and may consist of academic half days (Thursdays),
formal or informal teaching sessions by the chief medical resident (CMR), team
residents/attending, or other hospital staff, and of course, more rounds! This last iteration
provides an opportunity to wrap up on patient care outcomes for the day (depending on if
morning investigations that were ordered have returned) and to ensure that any outstanding
issues or concerns can be addressed and notified to the on-call team to be aware of. Depending
on the attending, the afternoon rounding may involve actually visiting each patient, where
bedside teaching will be provided, or simply teaching delivered during patient discussion at the
table. Regardless of the format, students are expected afterwards to write a brief progress note
update on their patients, order any new desired investigations, and complete any discharge
summaries they may have outstanding. This means the day can end anywhere between 4pm to
7pm, depending on what needs to be done and how long the afternoon rounds take.
THE OVERNIGHT: CALL SHIFTS

Call in internal medicine is full day and overnight and occurs on a 1 in 5 schedule (some sites
may have 1 in 4 at times). During the daytime, the senior resident will be down in emergency to
accept any consultations that are called in by emergency department physicians (EDP) and will
triage these patients based on acuity, complexity, and variety of experience to a member of the
call team. As this will be done in a balanced fashion, students can expect roughly every 4th to
5th patient that is referred to be assigned to them, depending on the size of the team.
117
Once assigned, students will see the patient, take a complete history and physical, formulate a
differential diagnosis and preliminary plan (investigations, treatments, admission orders), then
review with either the senior resident or staff attending regarding the patient. Once this review
has occurred and has been discussed, orders will be written and sent, and the patient will either
be admitted to the ward and become assigned to the student for daily rounding, or will be deemed
fine to be discharged or referred to an alternative specialty. The process repeats as patients are
referred to internal medicine and, depending on the night, each student can expect to do
anywhere from 2 to 4 consultations. If lucky, these will come during the daytime or early
evening. If not, they will stack up together after midnight and sleep will only be wishful thinking.
Thus it is advised to all students to nap when theres downtime, and go to bed early if one
doesnt have any pending consults.
The next morning, admitted patients will be reviewed with the staff attending, more morning
orders will be written, and then assigned patients will still be rounded on by students and
reviewed with the team as per normal. Students are officially released post-call by noon at the
latest, but in practicality this may not always occur as theres always work to be done, and on
some days students may stay until 3pm or later post-call afternoons.
THE GEAR: WHAT TO BRING & CARRY

The choice of what to carry around is important, as students can expect to be on their feet for a
good portion of the day and be walking around quite a bit. Thus less is more. Essentials include
ones phone and pager, the patient ward lists, pen and paper, a stethoscope, a white coat, and an
internal medicine reference such as the popular Pocket Medicine or Approach to Internal
Medicine books. Advisables include a drug reference manual, a bottle of water, and some
portable snacks (ex. granola bars). Although one could, most students opt to not carry their
penlight, tendon hammer, and tuning fork with them (but do have them available somewhere in
case they become required).
STAYING IN THE KNOW: THE BEST WAYS TO KEEP TRACK OF

PATIENTS AND OTHER INFO
This comes down to personal preference. Some choose to write directly on the patient ward lists
(although space may be limited), others use scrap paper or coiled notebooks, and some simply use
their memory (although impressive, this is unlikely to be effective at our level, and is not
recommended). You may also want to keep track of progress notes and the patients current
inpatient medicine list. This way, if one ever needs to refer back to what happened yesterday, or
look up quickly what medications or dosage the patient is currently on, its available at the
moment. It also helps to make checklists with boxes beside to-do items for each patient to keep
track of tasks.
118
BECOMING AN EXPERT: RECOMMENDED READING

There are a variety of resources available for reading, and which one to use is dependent on a
students learning style. A basic requisite is a pocket reference for when on the wards, such as
Pocket Medicine (aka. the green book, or whichever colour corresponds to the edition) or
Approach to Internal Medicine by David Hui. Beyond this, however, it also helps to have a
more comprehensive book for at home reading, and the options vary:
if one likes flow and details in the text and information: Blueprints, Up-to-Date
if one likes only key facts and memory aids: First-Aid, Toronto Notes
if one likes quizzing Q&A with explanations: Lange Q&A, Pretest, Deja Review
if one likes patient-based teaching cases: Case Files
Its recommended to just pick one reference and read that completely initially (ex. #1 or 2 above),
then follow that with a reference of a different type for practice (ex. #3 or 4), rather than
simultaneously referring to multiple sources erratically.
WHAT THE HECK WAS THAT?: HOW TO STUDY DURING THE

ROTATION
One studies any chance they get, in any form they can get. This includes day-to-day tasks, such
as during rounds, when seeing patients with staff or residents, during reviewing of new
consultations while on call, teaching sessions, or when theres spare time with residents. It is also
very important to learn around patient cases, as this will both help to retain the knowledge, as
well as to improve ones patient care management. Both staff and residents are more impressed
when students are well-versed in their patients condition(s) and what should be done regarding
them, which inspires them to teach students in more detail beyond just the basics.
When outside of work, commit to reading a set number of topics or pages from a book of choice
every night, and after 5-6 weeks one will realize that one has finished the majority, if not all, of
the book. On weekends, take the extra time to go back on what was learned during the week and
review key facts, such as diagnostic criteria, mnemonic memory aids, and approaches to
conditions. The choice to make flashcards is entirely up to individual preference. Although they
can be time consuming, they do prove useful when it comes time to quickly review in the week
prior to exams.
Finally, make sure to maximize downtime as well as the 2 weeks of outpatient care! Downtime
can occur while on call in the evenings, while waiting for the team to all gather for rounds, or on
the commute home. Every little bit of reading helps!
119
GETTING PIMPED: WHAT THE DOCTORS TEND TO ASK

Questions are usually patient-centred, and may relate to common presenting symptoms,
differential diagnosis, criteria for ruling in or out diseases, and treatment/management plans.
They may also ask more broadly applicable questions such as approaches to interpreting lab
values, chest x-rays and ECGs. It is for these reasons that it is helpful to study around patient
cases each night in advance of reviewing them with staff and residents the following day.
Being grilled, pimped, or put in the hot seat can be a nerve-wracking experience and may
lead to one blanking completely in their panic. Just always keep in mind that doctors are asking
in order to teach, not to embarrass. If one doesnt know the answer, one should admit that, then
make a formulated, logical guess at it. At the very least, it shows the doctor that one knows
personal knowledge gaps, but that one can take some sort of approach to the problem
nonetheless (and often end up pretty close to the right answer). It is never recommended to
pretend to know, as one will be burned by this more often than not.
There are times when questions will be of the what am I thinking?, in which it is difficult for
students to have any chance at knowing or even guessing the correct answer. Dont sweat or fret
over these questions, they happen, doctors recognize (sometimes) when theyre asking one of
these questions, and there isnt any significant expectation for students to have to get these
questions right. Just give it a best guess and once one finds out if it was right or wrong,
remember to store the answer in memory and dont get caught again next time.
HANDS ON: PROCEDURES YOU GET TO DO IN THIS ROTATION

The range of procedures one gets to do will vary depending on the patients one manages,
enthusiasm, and of course, a bit of luck. Any chance that comes up to do, or at least observe, a
procedure should be taken full advantage of, as another opportunity may not come up again
during the rotation. Common procedures that students may receive a chance to perform include
arterial blood gas draws, ECG placement and interpretation, DRE with occult blood testing, and
foley catheter insertions. Each of these are well within a students abilities, but should still be
supervised and guided by an experienced staff, such as a nurse or resident. Other less frequent
procedures in which students can observe, and perhaps assist with, include CSF sampling,
paracentesis, thoracocentesis, chest tube insertion, and joint aspirations. Be keen and keep on the
look-out for procedures, and one is bound to see and do some interesting things!
120
THE CHECKLIST: MUST-SEES AND MUST-DOS THAT YOU WILL

LIKELY GET DURING THIS ROTATION
There is a list of patient encounter objectives available on Medicol and the One45 logging page
for internal medicine, which includes conditions which students should have an opportunity to be
involved in the management of, or at least learn an approach to. These can vary from the
common such as chest pain, CHF, diarrhea, or anemia, to the more unique such as seizures,
thyroid disease, and splenomegaly. Regardless of the condition, however, any student should
have little trouble covering the majority of these patient encounter objectives through their
inpatient management, and any missing areas can be taught by residents on request, especially
during downtime while on call. Just remember to log encounters into One45 every week at
minimum, as any longer duration will result in one forgetting what theyve seen.
LEVELING UP: HOW TO PREPARE FOR THE EXAM

A good portion of learning will come from on the job experience and teaching sessions with
residents and attendings. However, there is undoubtedly a need to study on ones own in addition
to these learning opportunities if one is to pass the exams. Most students pick a study resource
based on personal preference, and in the end the choices are equivalent as long as it is matched to
ones learning style, and the student actually completes reading the resource.
It is highly recommended to pace the studying right from the start, rather than leaving it to the
last few weeks to cram. If one chooses 2-3 topics a day to read on during the first 6 weeks, they
should find that the majority of topics will be covered. During the last 2 weeks, a brief overall
review of conditions helps refresh and consolidate knowledge. A few days before the exam,
attempt numerous NBME style practice questions, in order to be accustomed to the mindset of
reading and answering questions quickly, as well as the level of understanding required by the
exam.
Some opt to create cue cards on various medical conditions for easy review closer to the exam.
This choice is up to each student, as creating the review cards can be time consuming and may
not be used effectively later on for studying, but the process of making them can be beneficial in
itself.
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THE FINAL BOSS: END OF ROTATION EXAMS

The internal medicine exams consist of an NBME, OSCE physical exam, and oral case scenario
exam, all occurring during the last week of the rotation. Typically the OSCE is at the start of the
week, and the NBME and oral exams are on the last day of the rotation.
The NBME exam is a standard 100 multiple choice question exam that is provided by the
American National Board of Medical Examiners, to be completed in a span of 2 hours 50
minutes. 60% or greater is required to pass the exam. Each question typically consists of a
patient vignette illustrating a presenting case with associated investigations and results, followed
by a clinical question with (usually) 5 multiple choice selections. As the exam is American, the
lab values will also be in US units, but a reference sheet of normal lab values with both US and SI
(international) units is provided, and students soon become accustomed to recognizing when a
lab value is significantly abnormal. The questions are notably longer reads than previously
encountered MC questions from 1st and 2nd year medicine exams, and have been known to
contain extraneous or excessive details not required to answer the question. As such, it is
recommended that examinees first glimpse what the question is asking, then read quickly through
the vignette before providing ones best answer and moving on to the next question. Time can be
lacking in the exam if every question is read meticulously and overanalyzed! All topics within
internal medicine is covered, but generally questions are focused around diagnostic criteria and
management of common cardiac, respiratory, and gastrointestinal illnesses/disease.
The OSCE exam consists of a 30 minute session with a clinical attending asking the student to
demonstrate various physical exam skills on a volunteer patient. A list of examinable skills is
provided at the back of the internal medicine clerkship guide, and fall under 4 system categories:
cardiovascular, respiratory, gastrointestinal, and other (hematological, endocrine, neurological,
and rheumatological). The attending will only request the student to demonstrate a specific
component or portion of one of the 4 categories (ex. demonstrate how to exam for JVP or
demonstrate an exam for ascites/abdominal distention), and will grade the student based on
demonstrated skills as well as interpretation of positive/negative findings. However, as the
attending may ask the student additional questions that could relate to other aspects of each
organ systems full examination, as well as the fact that the chosen component is random and at
the whim of the examiner, it means all aspects of the exam for each system still requires equal
study!
The oral exam consists of 2 stations, each with an unique case and examiner. The student will
read a brief case presentation of a patient and quickly organize their ideas and plan, before the
examiner enters the room and asks questions related to the case. They will provide additional
information and lab values, and prompt further discussion regarding differential diagnosis,
provisional diagnosis, and treatment/management plan. Upon completion, students will switch
stations and complete the other case with the other examiner. Cases are generally based around
common illnesses/diseases that present on the ward or in emergency to internal medicine, and
the goal is to assure students have a basic understanding to diagnosis, and an approach to
management, of these conditions.
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THE MAP: SITE SPECIFICS FOR THE ROTATION

*To find out where to go on the first day, CHECK YOUR EMAIL for a message from the
department. Listed is where students have met on day one in the past.
Site
SPH
VGH
RCH
Where
students have
met on day
one in the
past.
Cafeteria conference room on 4th

floor to meet with Chief Medical
Resident. Everydays morning
report is also here.
Conference room
of 14th floor of
Jim Pattison
Pavilion.
Medical Education
Center located in
the basement
adjacent to the
library, call rooms
and outpatient clinic
Where can I
store my
belongings?
7th floor ward A has a medical

student room with lockers near the
far back corner. Bring your own
lock.
There are lockers

on both the 3rd
and 14th floor for
students. See
orientation
manual.
You will be assigned

a locker next to the
resident/student
lounge.
What kind of
teaching is
done at this
site?
Morning report, noon rounds,

academic half days, and CMR
teaching is standard. There are also
pharmacy and infectious disease
teaching once per week.
Morning report,
noon rounds,
academic half
days, and CMR
teaching is
standard.
Morning report,
noon rounds,
academic half days,
and CMR teaching
is standard.
Is this a
good site to
choose for
someone
interested in
this
specialty?
Any of the sites are equivalent

choices for someone interested in
Internal Medicine, as they all
provide good teaching and
exposure to a variety of patients.
The teaching experience is
somewhat random depending on
the quality and personalities of
your attendings and residents.
see left
see left
What are
common/uni
que problems
patients at
this site
have?
You will see a higher proportion of

drug/alcohol abuse patients here.
MRSA/VRE is also more
prevalent here.
There will be
numerous
complex patients
with multiple
comorbidities
here. Otherwise
the range of
patients is
generally well
balanced.
You will be exposed

to bread and
butter cases such
as CHF, COPD,
CLD, CKD etc.
Because of the
smaller patient
volume, additional
reading is required
for more obscure
cases
123
THE LIST: 10 THINGS TO KNOW

5 symptoms you will need to
know the differential and
management for:
5 things you will be asked to

inter pret/ demonstrate an
approach to, or perform:
1. chest pain
1. reading an ECG
2. shortness of breath
2. reading a chest x-ray
3. GI bleed
3. performing a DRE for occult blood
4. dizziness/lightheadedness
4. interpret abnormal lab values

(ex.lytes, CBC)
5. fever
5. interpret blood gases (ex. acid-bases,

PCO2)
THE SUMMARY: CLOSING THOUGHTS AND ADVICE

Internal medicine is a tough rotation. Theres simply no way to sugarcoat it. You will feel
stressed, you will be tired, and you will have days where you want to break down because theres
so much to do. Many people do not actually enjoy this rotation, nor do they learn as much as
they could have due to time constraints and fatigue. However, even those who arent IM-inclined
can recognize the unique opportunity provided to actively diagnose and manage patients, a
responsibility that may not be available again in any other rotation.
Regardless of your interest in this specialty, be keen, reliable, and amiable with your team, and
youll find that residents and attendings become far more enthused to spend time teaching you.
If you dont understand anything, ask anyone you can for help, including the team pharmacist,
the nurses (they know tons!), the physiotherapist or the social worker. For the most part everyone
around you is willing and happy to teach med students as long as there is time, and as long as the
student demonstrates a willingness and eagerness to work hard. If you ever dont know
something or didnt do something, dont try to bullshit or lie, youll be caught and the outcome is
far worse than admitting you have no idea or hadnt completed that task. Dont be discouraged
on the bad days, everyone has them, and you recover quickly the following day if mistakes have
been made.
Post-call days will be especially tiring, so dont feel guilty if you end up sleeping most of the
afternoon and evening after you get home, as this is much needed if youre to return to work fresh
the next day! Given that fatigue can be an issue on this rotation, make sure you get enough sleep
each night. Also, being busy on service, you may not always have time to grab a bite, so
definitely carry something quick and easy to eat (ex. granola bar, banana, etc) with you at all
times, and there is certainly no shame in grabbing extra leftover food at the end of noon rounds!
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As difficult as internal medicine will be, by the end all students come out of it having learned
more than they couldve imagined. They become far more adept at diagnostic and treatment
skills, and have thus become better medical students because of it. Even if you dont like the
rotation or specialty, youll still feel like youre closer to becoming a doctor than you have ever felt
during the first 2 years of med school!
125
Pediatrics
Written by Andy Chen and Leslie Anderson, MD 2013
Edited by Rachel Lim, Lawrence Haiducu, and Christine Kang, MD 2014

Pediatrics is one of the big 3 rotations and consists of a month of inpatient pediatrics at a
major hospital site (BCCH, LGH, RCH, or SMH) and a month of outpatient care in a
community or subspecialty clinic. Pediatrics isnt just applying adult medicine on a smaller scale!
One can almost regard pediatrics as a standalone rotation, as the skills and knowledge required is
often unique to the specialty, so going through internal medicine or surgery beforehand may not
even be particularly advantageous!
Students will be sent an e-mail, a month or two prior to the start of the rotation, asking them to
choose which inpatient site and outpatient electives they would like for the rotation. As this is
first come, first served, respond quickly! Each inpatient site choice comes automatically with one
outpatient assignment, and the other outpatient option will be assigned randomly later.
Regardless of which hospital site or which electives a student chooses, the vast majority of
students enjoy their experiences. Though children can be challenging to work with, they also
present an opportunity to have a lot of fun and truly feel appreciated. Plus, its the only specialty
where playing on the job actually has its uses!
THE CLINICS: OUTPATIENT OPTIONS

The month of outpatient pediatrics consists of two 2-week electives in a variety of subspecialties.
These can occur at various sites, but the majority are at BCCH. Depending on the elective,
students may be involved with clinics, inpatient consultation, or seeing new patients presenting in
the emergency. There is generally no call during the outpatient electives, but depending on the
subspecialty, students may be able to request additional shifts or volunteer to be on call if they are
interested. Available options may vary from year to year.
126
Cardiolog y (BCCH: a surprisingly busy and intense schedule but with exposure to some
fascinating conditions)
Community pediatrics (various locations: a fairly relaxed experience with bread-andbutter peds)
Developmental pediatrics (Sunny Hill)
Emergency (BCCH: fast track and acute care, most students find this rotation to be very
enjoyable with lots of learning)
General pediatrics (BCCH Ambulatory: referrals from GPs for common pediatric
issues, as well as follow-up care for recently BCCH discharged newborns)
Hematologic patholog y (BCCH: a chill rotation with afternoon tea time and an
interesting perspective on blood disorders)
Multidisciplinar y (various pediatric clinics, such as dermatology, oncology,

rheumatology)
Newbor n unit (SPH or BCCH: newborn exams at deliveries and checking on the babies
in the nursery. Lots of cuteness.)
Neurolog y (BCCH)
Richmond outpatient clinic (exposure to a variety of areas in peds)
For the outpatient assignments, students do also have the option of applying for a Directed
Learning Option (DLO). They can choose an area of pediatrics that isnt offered among the
outpatient options and ask the rotation administrators if that area would be acceptable for part of
the outpatient experience. If it is, applicants will be given the name of a contact person, and if
theyre able to find someone who is willing to take them on for 1 or 2 weeks, then that DLO
elective becomes a part of ones outpatient pediatric experience. Some examples include peds
orthopedics, peds dermatology, peds plastic surgery, and peds anatomical pathology. If one is
interested in a DLO, make sure to begin the application process early!
Memorable Moments
First day on pediatric emergency, patient's triage note states: "Chloe X,
7yo, respiratory distress." I took the chart, go to waiting room and called
out for Chloe. Chloe and her father came in to the examination room.
Chloe looked like a big girl, at least 5', but what the heck, kids are
growing up fast now days... I asked about her resp distress, she said she
had a little bit of SOB when she fell at PE today, but the main problem
is her sore and swollen wrist. Okay, triage might have gotten the wrong
chief complaint...
So I did a hx/px for resp distress and sore wrist, then reviewed with
staff. Staff took a look at the patient and asked me "this patient is 5' tall,
cooperative and articulate, goes to highschool (she was wearing uniform
from a private school), did you really think she's 7?" Turns out, this
patient is 15. It just happens that day there were 2 Chloe's in the waiting
room, and the 7yo. Chloe was in the bathroom. What are the chances.
Lesson: always check surname/age/occupation to make sure you see
the right patient.
127

I love to cook and for me, there is nothing
more rewarding that eating a good meal at
the end of every day. I made a point of
eating well despite my busy schedule by
being organized. I created a weekly menu
and found a store that would do a weekly
shop for me (at Whole Foods on Cambie, I
just had to swing by to pick up the
groceries). I also prepared everything that I
could ahead of time (pasta, meats, sauces
etc). Then, when I returned home after a
busy day, all that I would have to do was
combine the ingredients and voila: a dinner
that does not include KD!

The start time for inpatient pediatrics varies from site to site, and may be as early as 7:30am
(BCCH) or as late as 9am (SMH). In general, the morning starts with patient rounding which
could take until noon or even the whole day depending on the number of patients being carried
by a team/individual. The day ends late afternoon/early evening. At BCCH, evening handover
is at 6pm and students usually leave at 7pm. At SMH, M/W/F afternoons are outpatient clinics
that end at 4-5pm; T/Th is independent study time and academic half-day ending at 4pm. LGH
and RCH also have afternoon outpatient clinics throughout the week, but BCCH is 100% ward
care. Depending on the site, students may have certain days assigned to experience the NICU
(neonatal intensive care unit) or to cover the newborn nurseries and wards.
The schedule varies for outpatient options and can start early (7am for cardiology), or later (9am
for general pediatrics). As expected, the day ends at various times as well, depending on
workload and scheduled appointments to the clinic but on average, the typical outpatient clinic
only books appointments until 4pm.

At BCCH, call shifts are consolidated into a single week of night float. This means students will
have the daytime hours off (for sleep) and report to the wards for handover at 6pm. Theyll be
responsible for all ward management issues and concerns that may arise overnight, as well as
consults that arrive in the ED, until morning handover the next day at 7:30am. Once handover is
completed, they may go home for the day but will return that night to repeat the process. Night
float week typically occurs for 6 nights of the assigned week and there will also be 2 additional
weekend call shifts during the month. Its one of the most grueling experiences of 3rd year but
its also the best learning opportunity available for pediatrics. As ones sleep schedule will be
greatly disrupted by the day-night reversal, it is recommended to charge up on sleep prior to the
week.
At other sites, call is on average 1 in 4, scheduled in the typical fashion throughout the month.
During the day, students work with either the pediatric attending or resident on call to cover
emergency consultations or new deliveries. Overnight, they are also responsible for any ward
issues that may arise. The workload overnight varies based on the number of consultations and
deliveries that occur and thus students may get a reasonable night of uninterrupted sleep, may be
up the entire time or may be regularly woken every hour. The pediatrician or resident is first call
to all deliveries, usually 5-10 minutes before they occur and typically they will page the student
with the delivery suite number while theyre on the go. This means students shouldnt be
surprised if they have less than 5 minutes between when theyre paged and when they have to
rush down to the delivery suite to catch up; being a light sleeper and a fast out-of-bedder is a
necessity!
128

There are the usual items one requires for most rotations, including a stethoscope (with a
pediatric side if possible), something to write with and the patient list or a notebook to keep track
of patients vitals/issues. There are, however, also some unique items to pediatrics, such as a
calculator (many pediatric staff use a small clip-on one from Staples) or an equivalent device (ex:
cellphone), as this is a necessity for calculation of fluids and weight changes. Another unique
item that often is useful is something cute on ones stethoscope, such as a clip-on stuffed animal
or toy. Whitecoats are neither required nor recommended!

Usually students will receive a patient list in the morning and notes can be written directly on this
sheet. If one needs more room, a small notebook is helpful. Some people bring sheets preprinted with areas to write vitals, fluid ins & outs, overnight issues, lab results etc. Another
alternative is to use cue cards for each patient.

students learning style. It is up to the student if they wish to carry a pediatric pocket reference,
which can be useful but not always necessary. There are a variety of pediatric review books for at
home reading:
if one likes flow and details in the text and information: Blueprints, Up-to-Date
if one likes only key facts and memory aids: First-Aid, Toronto Notes
if one likes quizzing Q&A with explanations: Lange Q&A, Pretest
if one likes patient-based teaching cases: Case Files
simultaneously referring to multiple sources on topics erratically.
Two other references that are highly recommended are the online CLIPP cases (see below) and
the website www.lear npediatrics.com , which contains numerous pages with approaches to
common pediatric problems as well as physical examination videos to help prepare for the
OSCE.
Although the department provides a pediatric reference book for the rotation, it is long and
dense, and may not be the most efficient use of reading time. It does, however, function as a
pocket book for bringing around while at the hospital.
129
WHAT ARE CLIPP CASES

CLIPP stands for Computer-assisted Learning In Pediatrics Programs, and is a series of 32 online
cases developed for medical student learning. Each of these cases are based on a simulated
pediatric patient; information regarding history, symptoms, and physical findings are provided
sequentially, similar in style to PBL cases. Interspersed with this information are questions posed
to the reader to stimulate critical thinking and learning along the way. Each case requires roughly
30-40 minutes to complete. There are also case summaries downloadable at the end of each case
that serve as simple review sheets for the exams. While completing the cases, it is recommended
to read each of the expert advice windows for each section of a case. Although at times the
information there may be redundant or obvious, it still helps to read these windows, as on
occasion, there is useful or interesting knowledge that they provide.
Log-in access to these CLIPP cases will be provided by the department (they will e-mail
inforomation or it can be found in the pediatrics manual). Students will be required to complete
at least 20 of the 32 cases (no marks associated, for completion only). However, as they are all
helpful, it is highly recommended to complete all of the cases, as statistics show the number of
CLIPP cases completed correlates to a students NBME mark. If one was to work through all of
the online cases, then almost every major pediatric condition that students are expected to know
will be covered. At a pace of one case each day, students could work through all of them within
a month. They can then utilize the 2nd month to review these cases and other study material.
A list of the cases by topic and more information regarding CLIPP can be found at
http://www.med-u.org/vir tual_patient_cases/clipp/ .

ROTATION
As with any rotation, its important to maintain a steady pace of studying throughout the
rotation to avoid being overwhelmed before exams. Pediatrics has a lot to learn and the best way
is to center ones studying around patient cases that are encountered. Try to read about various
conditions as you encounter them, and remember to complete the CLIPP cases steadily through
the rotation to cover a wide variety of topics.
Take careful note of how fluid status and feeding/weight gain is evaluated and managed then
apply this knowledge to subsequent patient cases. At all new deliveries, perform the full newborn
assessment with the attending or alone even if it has already be done by the pediatrician as the
more one attempts these exams, the more efficient and comfortable one will be with them.
130

The majority of questions will be patient case based and will occur during rounding. A common
focus for all newborns and infants is appropriate feeding, weight gain, urine output, etc. (see The
numbers of pediatrics section below). Other questions will focus on how to differentiate
between common pediatric conditions such as RSV, croup and asthma. Detailing ones approach
to treatment and management is also important and often this involves careful monitoring of
feeding to ensure appropriate weight gain, or the provision of nasal prong oxygen to maintain O2
sats. During newborn deliveries, expect questions regarding APGAR assessments, newborn
exams and possible ante- or post-natal complications. The latter, for example may relate to intrauterine growth restriction (IUGR), macrosomia, transient tachypnea of the newborn (TTN), or
respiratory distress syndrome (RDS).

Students may not get to do very many procedures during pediatrics, as working with children
tends to be a bit more sensitive than with adults and has more risks involved with inexperience.
However, one may get to see or assist with starting IVs, performing lumbar punctures, inserting
NG tubes and administering vaccinations, depending on the area of pediatrics involved.

for pediatrics, which includes conditions that students should have an opportunity to be involved
in the assessment of, or at least learn an approach to. It is generally not difficult to complete
these objectives, especially while on call. Should there be any activities not observed or
performed, one can approach residents and attendings to provide a brief teaching session on
these topics.

Use the inpatient experience and learn around each case and presentation then apply what one
knows to each re-iteration of a case that arises. There should also be plenty of time during the
outpatient month to study and complete CLIPP cases and, as long as a steady pace is maintained,
there should be no requirement for cramming before the exam. Case Files for Pediatrics was a
popular book, while Pretest Pediatrics was helpful for practice questions. The academic half-days
also cover a lot of the major topics as well, so it is worthwhile to attend.
The few days before the exam, it is also recommended to review some of the more specialized
pediatric topics that one may not have encountered during ones inpatient experience, such as
pediatric hematology/immunology, genetically inherited conditions and developmental or
neurological conditions. These topics may arise on the NBME and without having some
familiarity with the subjects, it is quite difficult to discern the correct answers. Other more
common subject areas should have been consolidated already over the two months into ones
repertoire of knowledge and thus would only require a brief refresher as needed.
131

The pediatric exams consist of an NBME and OSCE/oral exam, both occurring during the last
week of the rotation.
American National Board of Medical Examiners to be completed in a span of 2 hours 50
(international) units is provided and students soon become accustomed to recognizing when a lab
value is significantly abnormal. The questions are notably longer reads than previously
encountered MC questions from 1st and 2nd year medicine exams and have been known to
the vignette before providing ones best answer and moving on to the next question. One can run
out of time if one meticulously reads and overanalyzes each and every question!
The OSCE/oral exam is in a multi-station exam format that includes a history station, a physical
station, a counseling/giving of information station (ex. breastfeeding), and two written stations
where participants will be asked to interpret lab data, an image, graphical data, etc. The OSCE
tends to stick to the bread-and-butter pediatric issues and most people perform quite well during
this exam.
132

*To find out where to go on the first day, CHECK YOUR EMAIL for a message from the department. Listed is where
students have met on day one in the past.
Site
Where students
have met on day
one in the past:
Go to the wards on
the 3rd floor (3M)
and meet your
residents at the
main desk (also
called The Fish
Bowl, because the
area is enclosed in
glass) for handover
from the night
BCCH
team. There are
two different teams
- both take general
pediatric patients,
but the Blue Team
takes cardiac
patients and the
Green Team takes
nephrology
patients.
Where can I
store my
belongings?
You can use the
lockers in the
locker room on the
2nd floor (youll be
shown where it is
during orientation),
but most students
just put their coat
& bag under one of
the desks in the
main area.
What kind of
teaching or
Is this a good site for
academic
someone interested in
sessions are
this specialty?
there at this site?
The residents do
teaching when they
can. Youll get the
most teaching when
you do your night
shifts, since the
residents will have
more time to teach.
Youll also go to
Grand Rounds on
Friday morning and
Advances in
Pediatrics, a
hospital-wide
teaching session, on
Fridays at noon.
Yes and no. Youll get

exposure to some of the
crazier health problems, but
you might not spend much
time directly with the
attending, so getting a
reference letter may be
more difficult. You also
might be turned off of peds
if you do CTU at BCCH its quite intense and not
really representative of
what peds is as a specialty.
What are common

problems patients
at this site have?
Bronchiolitis, DKA,
nephro problems and
cardiac issues. All rare
diseases and unique
conditions in BC will
likely be transferred to
BCCH for care and
management as well.
What is the call

schedule like?
You will do 6 night
shifts in a row and
two weekend days
(one Saturday and
one Sunday).
Otherwise, you
work Monday to
Friday but the days
can be long, starting
at 07:30 and going
until evening handover is finished,
which can be 18:30
or later!
Site
Where students
have met on day
one in the past:
The first day will

start with a site
orientation with
Barbara Gourley,
the site education
coordinator. Her
office is in the
Creekside building
on 94A Avenue
behind the main
SMH
hospital building.
Each morning
after that, students
report to the main
desk at CYS (Child
and Youth
Services) to divide
up patients and
start rounding.
You will receive an
email prior to your
rotation indicating
where you should
meet
RCH
Where can I
store my
belongings?
What kind of
teaching or
academic
sessions are
this specialty?
there at this site?
What are common

problems patients
at this site have?
What is the call

schedule like?
There are lockers

for students by the
call rooms on the
2nd floor of Area F
(orange line).
Students can also
drop their bags off
in the residents
office at CYS or
under the table at
the main
desk/nurses
station.
As the one pediatric

resident at SMH is
generally too busy
with the newborn
and NICU suites to
provide teaching to
students, the
majority of learning
will be during the
rounds on
inpatients each day
with the attending
(pediatrician of the
week). There are
also
videoconferenced
academic half-days,
grand rounds, and
Advances in
Pediatrics sessions.
SMH is very suitable for

students interested in bread
and butter pediatrics, or
those planning to have a
pediatric heavy patient
population in their family
practice clinic. Although
there are no rare or unique
diseases that present usually
(these go to BCCH), SMH
provides ample opportunity
to learn and practice caring
for the most common
pediatric conditions.
Respiratory: RSV,
croup, asthma
GI: poor feeding,
vomiting, diarrhea
other: seizures, rashes,
jaundice
SMH has the 2nd

highest number of
deliveries in BC
(after BCW) and an
extremely busy
pediatric emergency
unit, and thus there
will be plenty of
action going on
during call shifts.
On-call is in-house,
approximately 1:4.
Lockers are
available in the
residents lounge
area in the
basement
Residents are very

good at making
time to teach. In
addition, the staff
are also very willing
to teach. The
academic half days
are very useful
Because of the small size of

the pediatric department
and the limited number of
patients that you will see
each day and during call,
these sites may not be ideal
for students interested in
pediatrics. However,
because you work closely
with staff, both sites are
great for obtaining
meaningful references.
Respiratory: RSV,
Calls are in-house,
croup, asthma
1:4.
GI: poor feeding,
vomiting, diarrhea
jaundice Respiratory:
RSV, croup, asthma
GI: poor feeding,
vomiting, diarrhea
jaundice
Site
LGH
Where students
have met on day
one in the past:
Where can I
store my
belongings?
Report to Dr.
Glenn Robertson at
0800-0830 hrs on 3
East (Pediatrics).
Email will be sent
out for exact time.
Lockers are
available in the
Doctors lounge in
main lobby (lock
included), in the
nurses lounge on
3East (no
valuables), and on
labor and delivery
floor (clothes only,
no lock).
What kind of
teaching or
academic
sessions are
this specialty?
there at this site?
Teaching - 1/2 day
at BCCH is video
conferenced as is
Grand Rounds and
Advances in
Seminar D, across
from library at
LGH. Most weeks,
3 hours of teaching
is offered in a
schedule session
with Dr. Robertson.
Absolutely, work 1 on 1
with staff. Lots of good
opportunities to see what
General peds is like. Good
opportunity for reference
letters.
What are common

problems patients
at this site have?
Inpatient - pneumonia,
dehydration,
gastroenteritis,
jaundice, meconium
deliveries, prematurity,
feeding issues, UTI, csection, fetal heart rate
distress, medically
unstable eating
disorders
Outpatient developmental
(ADHD, autism),
asthma, UTI,
eczema, failure to
thrive (FTT) diabetes
(diabetic clinic with dr
stock), medically stable
eating disorder,
murmur, orthopedic
issues, well child care.
What is the call

schedule like?
On-call is in-house
and approximately
1:4-5. Typically 2
weekend
days.During the oncall hours, students
will be present at
newborn deliveries
(32 weeks upward)
and see a variety of
pediatric consults.
THE MATH: NUMBERS OF PEDIATRICS

30 g/day
newborns/infants should gain approximately this amount of weight per day
10%
newborns can lose up to 10% of their birth weight in the first week, but should
regain this or more by the 2nd week at the latest
20 kcal/oz
energy content of breastmilk and standard formula (E20). Higher energy formula
may be E22 or E24 (22kcal/oz or 24kcal/oz respectively).
100150mL/kg
adequate amount of fluid intake (ie. breastmilk, formula, IV solutions) per day for
a newborn/infant to remain properly hydrated. Use the 100-50-20 mL/kg rule.
6-8/day
number of wet diapers per day in an adequately hydrated infant
1-2
mL/kg/hr
adequate amount of urine output for a newborn/infant. This can be determined

by weighing wet diapers and deducting the dry diaper weight.
5-10-15%
3-6-9%
infant (<20kg): weight loss % in mild - moderate - severe dehydration

child (>20kg): weight loss % in mild - moderate - severe dehydration
the number of chances you get to earn and keep the trust of a child. Dont say
something wont hurt if it will (a.k.a. shots), dont say something wont taste bad if
it does (a.k.a. antibiotics), and dont promise you wont do something that you
know youll have to (a.k.a. physical examinations).

5 common pediatric issues to know
about and differentiate
5 aspects/par ts of a pediatric histor y that

you shouldnt forget to cover (de pending on
patient)
1. respiratory problems (croup, RSV and

asthma)
1. developmental history (ie. milestones, delays,

failure to thrive)
2. fluid/feeding problems (dehydration, no

weight gain)
2. pregnancy and birth history (ie. complications,

drug and EtOH use, APGARs, pre/post-natal care)
3. seizures (febrile vs non-febrile)
3. ins and outs history (ie. fluid intake, eating,

diuresis, bowel movements, weight gain)
4. GI problems (vomiting, diarrhea and

constipation)
4. HEADSS assessment (home, education/

employment, activities, drugs/diet, safety/suicide)
5. physical injuries (burns, trauma, and

abuse)
5. informant and social history details (ie. whos

providing info, who lives at home, hows school?)
136

Many students are scared of pediatrics as it is a new and foreign world of medicine. Not only is
there the pressure of treating ill children, but there are the difficulties of working with concerned
parents as well. Some students have difficulties knowing how to appropriately interact with
children or teenagers during the interview. These are not skills that come naturally to all but can
be improved through observation and practice. Watch children play, observe how they interact
with their parents and environment; Tailor your approach to the age group of the patient but this
isnt to say that you should patronize or ignore children/teenagers during the interview, as they
are usually far more astute and intelligent than they receive credit for. Instead, avoid medicalese
and jargon, adjust your voice tone to be warm and friendly, get down on your knees or into a
squat to be at their level and smile!
Although during the first week or so of the rotation, you may feel completely lost and confused in
the foreign territory that is pediatrics, it doesnt take long to get the hang of the specialty and you
can focus on learning for the rest of the rotation. Also make sure you stay on the good side of
the nurses. Theyre extremely knowledgeable and they can also be rather protective and
territorial of their pediatric patients. Introduce yourself early on, be courteous, genuine and
reliable and youre far more likely to receive help from them rather than being pushed aside
because they dont trust your care and skills.
There is lots to learn, much that students can do to help, and definitely tons to enjoy! Pediatrics
can often become the most rewarding of experiences among all the rotations during 3rd year.
This occurs regardless of the outcome of the patient case, as not every case has a happy ending,
but with compassion and enthusiasm for providing the best possible care to sick children, both
your patients and their parents will appreciate you immensely in the end.
137
Surger y
Edited by Rachel Lim and Lawrence Haiducu, MD 2014

Surgery is one of the big 3 rotations, and is comprised of 4 weeks of general surgery service
and 4 weeks total of subspecialty electives (students rotate through 2 electives, each 2 weeks in
duration). The order of whether a student has their general surgery month first or subspecialties
month first is assigned by the program coordinator. During the general surgery portion of the
rotation, students will be part of a team along with other students, residents, and attending
surgeons and will be responsible for the pre- and post-operative care of surgical patients, as well
as observing or being involved with surgeries. The subspecialty electives (selectives) offer a choice
of fields, each with their own schedule, activities, and responsibilities.
Renowned for having the earliest start time of any rotation, it truly makes students appreciate
and miss 8am start times for 1st and 2nd year PBL. The rotation provides students an
opportunity to appreciate what general surgery involves and offers a glimpse of unique
subspecialties that may be of interest. It also offers the chance for students to be involved as 2nd
assists (sometimes 1st if youre lucky) during surgical procedures, putting you up close and
personal to the internal cavities of the human body. It also gives students a chance to practice
their suturing and tying skills until it becomes second nature!
THE CHOICES: SUBSPECIALTY ELECTIVES (SELECTIVES)

Prior to the start of the surgery rotation, students are offered the opportunity to rank their
preferences for various selectives, each 2 weeks long.
The options include (availability of hospital sites may vary from year to year):
Cardiovascular Surgery (SPH, BCCH)
Neurosurgery (VGH)
Pediatric General Surgery (BCCH)
Plastic Surgery (VGH, SPH, RCH/SMH)
Otolaryngology (VGH, SPH, BCCH)
Radiation Oncology (BCCA-Van, BCCA-Surrey)
Thoracic Surgery (VGH)
Urology (VGH, SPH, BCCH, LGH)
Vascular Surgery (VGH, SPH)
138
Descriptions of each selective can be found on Medicol under Year 3 -> Surgery.
Each selective has its own unique experience and students should rank according to their
personal interests. Like many other ranking lotteries, placement in exactly what one wants is not
guaranteed, but generally most students receive their top preferences. Although students may not
be exposed to the other selectives, the academic half day lectures will cover topics within those
specialties, and thus those areas are still testable material for the end of rotation exams.
Memorable Moments
I started my surgery rotation in the subspecialty of thoracics, where I learned that the ORs are kept quite cold in
order to keep the surgeons, who tend to overheat in their Gortex gowns under those bright lights, cool. When I
started my next subspecialty, pediatric general surgery, I learned that since babies cant regulate their
temperature very well, the ORs in those cases need to be kept much warmer and I soon discovered why
keeping the room cool is so much better for the surgeons!
I was scrubbed in as second-assist on a bowel surgery for a premature baby. Since our patient was so tiny, the
surgeons and I were crammed against each other, and also against the Baer Hugger (an inflatable warming pad)
that the baby was lying on. I was in charge of holding a retractor, and I had to hold it up in the air, because if I
let it rest on the patient, it shifted the tubes bringing oxygen to the baby. So, I was in an awkward position
wearing full gown and gloves under hot lights and pushed up against a hot warming pad and the body heat of
other surgeons, and I started to feel weird. First, I noticed sweat starting to drip down my back. Then I felt kind
of lightheaded. Then the nausea kicked in. I kept taking slow deep breaths, telling myself I was just fine, but I
really wasnt. I was quickly reaching the point where I was going to pass out, so I finally had to tell everyone
that I was overheating and needed to step away from the table. I sat down on a stool and put my head between
my legs. I was still so warm, so I took my gown and gloves off. My scrubs were soaked with sweat. Another
wave of nausea hit and I needed to run out of the room. A nurse followed me to make sure I was okay. She
pointed out that I was as white as a sheet and went to go and get me something to eat. Another couple of
nurses were in the change room where I ended up, and they made me feel better by sharing their stories of when
they almost passed out in the OR apparently it happens to almost everyone at least once! The nurse came
back with some juice, cheese, and a grape popsicle (the benefit of being at Childrens Hospital!) and I started to
feel a bit more normal, albeit a tad embarrassed. I definitely came to appreciate the cold temperature of adult
ORs and Im really glad I didnt pass out on our patient!

During general surgery, the typical day starts with morning rounding on pre- and post-operative
patients before the operating room (OR) starts. The precise time varies from site to site, but
typically most ORs start at 8am, with patients prepped and ready by 7:30am. Because of this,
rounding can start as early as 6:30am, depending on the number of patients the team has. After
rounds, the day varies depending on the assigned duties of the student. Some days the student
may be scheduled for the OR, during which they scrub in and observe/assist the surgeons and
residents. Others will involve day clinics in surgeon offices, in which new consultations or followup patients will be seen. Academic half-days occur every Tuesday and Thursday afternoon. On
call days, students will be on site to take any emergency consultations or ward calls. Most noncall days, students will be done by 4 or 5pm in the afternoon.
139
The weeks of subspecialty electives each vary in regards to their schedules and start/end times
each day, but in general will follow the same mix of activities such as OR time, outpatient clinics,
and call.

Surgery call is full day and overnight, and generally ends once patient rounds have been
completed the following morning. It is on average, 1 in 4, but varies from site to site. In general,
call is completed with a resident and attending, who are first-call for emergency consultations.
They will then prioritize the calls and assign the student to see the patients as needed. The
purpose of surgery consults is to deem whether a patient requires surgery acutely, if they require
admission and monitoring, if they can be sent home safely, or at times, if they arent even a
surgical case at all and another service should be called! In the first case (generally appendicitis
or trauma cases), these patients are often scheduled for emergency surgery, regardless of the time,
and thus students may find themselves in the OR at 3am or any other time of the night!
Students may also receive ward calls from nurses to assess patients during the shift, the reason for
which may vary from common internal medicine issues (ex. chest pain) or more surgery related
issues (ex. vomiting, patient pulled their nasogastric tube). After seeing the patient, students will
review with the resident and manage accordingly.
As a result of the on-call activity variability, students may find they get a full nights sleep, or be
awake all night seeing patients in the ED and standing in the OR.

Typically not much is required during the day when rounding. A pen, some paper, and a
stethoscope is often enough to complete patient rounds or emergency consultations. When
students are in the OR, little needs to be carried other than a pen and ones pager/phone to take
consults if one is on call. As scrubs will be the normal attire for OR days, it is difficult to carry
any reference books in the limited pocket space. Also, keep in mind that any weight one carries
in the OR is weight that one will be holding up while standing for possibly hours at a time!

Generally a patient ward list will be printed each morning for the members of the team, and
overnight handover issues can be written on this directly. Generally having a sheet of scrap paper
available at all times is also useful to jot down quick notes or write down information when
answering consult pages.
140

students learning style. Most students dont feel a need to carry a surgery specific pocket book
during the day, but having an internal medicine reference while on call could occasionally be
helpful if there are certain ward issues that arise. One should have one or more surgery review
books for at home reading though, and the options vary:
if you like flow and details in the text and information: Blueprints, Up-to-Date
if you like only key facts and memory aids: First-Aid, Toronto Notes
if you like quizzing Q&A with explanations: Lange Q&A, Pretest, Pestana
if you like patient-based teaching cases: Case Files
simultaneously referring to multiple sources on topics erratically.
Although the surgery department provides 2 textbooks to students for reference, the general
consensus is that these books are too dense and detailed to be high-yield reading, and thus one
should use an alternative source unless there are exorbitant amounts of free time available! The
caveat to this is that the first 2 to 3 chapters of the general surgery book focusing on pre- and postoperative management can be useful for the NBME exam, and that the subspecialty book may be
a reasonable reading resource if ones review book of choice does not contain a good chapter on
ones surgery selectives.

ROTATION
It helps very early on during the general surgery month to become well-versed in common
presentations of surgical conditions (see 10 things below) as well as how to manage them, as it
makes ones call shifts far easier and more efficient. When cases present on call, use them as
opportunities to review and utilize what youve learned, as this will help you consolidate
knowledge on the management of these conditions.
Beyond that, having a consistent pace in daily reading each night helps to cover all necessary
material. Do not neglect the subspecialty topics as these can all be testable on the oral exam as
well as the NBME (see What is the exam format? below). This material is best covered by
going to all the academic half day lectures, and reviewing those presentations throughout the
course of the rotation and before the exams.
141
The subspecialty weeks tend to present more available time and less fatigue usually than the
general surgery weeks, and thus it is recommended one use this time wisely to review and study
for the exams. Motivation to do this is harder to find if one is starting with the subspecialty
weeks before general surgery, but students will definitely appreciate it later if they stay on top of
their reading early!
Memorable Moments
During my pediatric general surgery selective, we had a child come
in with a volvulus that needed to be corrected right away. I got to
scrub in as second-assist for the really interesting surgery. The
bowel is actually pulled out of the abdominal cavity, untwisted, and
then replaced with the small bowel on the patients right and the
large bowel on the left to prevent future problems. Since the
appendix would end up on the left side of the body, which, if it
were to become infected, would present atypically for appendicitis
and could easily be missed until it was too late, an appendectomy is
performed as well. The fellow had just tied off the appendix at its
base, and the surgeon put the metal dish with the scalpel in front of
me. Would you like to do the honours?
I looked at him blankly, not quite getting what he meant, since my
usual job was limited to holding retractors and occasional suturing.
What do you mean?
You can cut the appendix off if you want.
My eyes lit up and I eagerly took the scalpel. I cut through the
wormy piece of bowel just above the tie the fellow had put on, and
dropped the now-detached appendix into the specimen container. I
couldnt stop smiling. I was a third year medical student and I had
just removed an appendix. How fantastic is that?!?!?

We all have healthy hobbies and
activities that keep us centered and
grounded. Music, dance, yoga, artwork
are just some examples. For me, athletics
is a must in my life and is one activity
that I was not willing to give up
regardless of how crazy my schedule
was. Knowing that spending a little time
keeping active every day was not
sacrificing study time but rather a tool to
help me be balanced and more
productive allowed me to a little
something every day guilt free. Even on
call shifts a good stretch or walk around
the hospital when I wasnt busy helped
me be successful!

Time in the OR is a prime chance for surgeons to ask students questions, and these are generally
centered around the current surgical case. Expect to be asked questions such as presentation and
differential diagnosis of the condition/disease, when surgery is indicated and what type of
surgery, post-surgical management, and of course, surgical anatomy in which youll be asked to
identify structures that can be seen (and sometimes those that cant!) This means its a smart idea
to pre-emptively review ones general anatomy notes for a given body cavity (usually
abdominal/pelvic in general surgery cases) prior to a day in the OR, including names of blood
vessels, nerves, and other structures. Students should check with the OR booking desk the day
before their scheduled OR day to find out what surgeries are on the slate for their surgeon, in
order to adequately prepare beforehand and impress their attending.
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As for time outside the OR, few questions are generally asked while rounding due to time
constraints, but do expect to be asked questions during the clinics as well as while on call. These
will again be centered around patients and relate to diagnosis and management of surgical
conditions. While on call, the key question will always be to answer does this person need
surgery, is this now immediately or later, and why? Thus its beneficial to study common
presentations of conditions prior to call shifts.
Although residents are generally very happy to teach students any chance that arises, surgery is
still a busy service, and often surgeons may not be used to finding the time to ask students
questions or teach. They may also be used to talking about casual life topics with other staff
during OR time, as many are skilled enough to essentially run on autopilot during surgeries and
multitask their attention. As such, students often need to be proactive and ask questions to the
surgeon in order to spark conversation and learn around a patient case. Not doing so may result
in a dissatisfying surgery rotation experience, as well as possibly some silent, awkward clinic/OR
time!

Most commonly students will get the opportunity to perform simple procedures in the OR, such
as helping to close incisions at the end of surgeries when they are scrubbed in. Surgeons typically
leave the last layer or two of tissue for the surgical resident to suture up and students can be
expected to help them cut, or at times even tie their own, sutures. Staple closures and dressings
can be completed by students as well. With patients on the ward, students may get the
opportunity to check incisions and remove staples if there is an extended stay post-operatively.
Other procedures that students may have the opportunity to complete include nasogastric (NG)
tube insertions, colostomy bag changes/cleanings, foley or IV insertions, and any other
subspecialty specific procedures.

for surgery, which includes conditions which students should have an opportunity to be involved
in the assessment of, or at least learn an approach to. These can vary from the common such as
appendicitis, small bowel obstruction, or gallstones, to the more unique conditions found in the
various subspecialties. Regardless of the condition, however, any student should have little
trouble covering the majority of these patient encounter objectives through their general surgery
month, and any missing areas can be taught by residents on request, especially during downtime
while on call. Just remember to log encounters into One45 every week at minimum, as any
longer duration will result in one forgetting what one has seen.
143

A good portion of learning will come from on-call experience and teaching opportunities with
residents and attendings. However, there is undoubtedly a need to study on your own in addition
to these learning opportunities if one is to pass the exams. Most students pick a study resource
based on personal preference, and in the end the choices are equivalent as long as it is matched to
ones learning style, and the student actually completes reading the resource.
It is highly recommended to pace the studying right from the start, rather than leaving it to the
last few weeks to cram. One should especially utilize their month of selectives as study time.
During the last 2 weeks, a brief overall review of common surgical conditions helps refresh and
consolidate knowledge. A few days before the exam, attempt numerous NBME style practice
questions in order to be accustomed to the mindset of reading and answering questions quickly,
and the level of understanding required by the exam.
And for the 3rd time, review the academic half-day lectures! There are 29 of them, true, but they
cover what one needs to know for the oral exam and they help for the questions related to
subspecialties on the NBME.

The surgery exams consist of an NBME and oral case scenarios exam, both occurring during the
last week of the rotation. There is no OSCE exam.
American National Board of Medical Examiners to be completed in a span of 2 hours 50
(international) units is provided and students soon become accustomed to recognizing when a lab
value is significantly abnormal. The questions are notably longer reads than previously
encountered MC questions from 1st and 2nd year medicine exams and have been known to
the vignette before providing ones best answer and moving on to the next question. One can run
out of time if one meticulously reads and over-analyzes each and every question!
Although the main focus of the NBME exam is surgery, many questions do require a baseline
knowledge of internal medicine principles as they ask about pre- and post-operative care, thus if
one has gone through their internal rotation, it is helpful for this exam. If surgery is ones first
rotation, it may be beneficial to put some time into a brief overview of common internal
medicine inpatient issues, such as cardiac, respiratory, or GI problems. One should also pay
attention to any chapters regarding pre- and post-operative management in their review books, or
in the general surgery textbook provided by the department at the start of the rotation.
144
The oral exam consists of four 20-minute stations in which a surgeon will present a case and ask
questions based off this regarding approach to history, physical, differential diagnosis, and
management. One station will be on general surgery, and the other 3 will be selected
subspecialties. In general, at least one station will be from one of the selectives the student
experienced. There are methods in which one can predict which stations can be expected, based
on the common shared selectives of students passing through each track as listed on the student
exam schedule, but this may not always be accurate.
Respect the oral exam. It can be very difficult if one does not adequately prepare. Prepare for
this exam through thorough review of the academic half-day lectures, which present management
approaches to commonly encountered conditions in each subspecialty (ex. AAA in vascular,
oncologic emergencies in rad onc, hand fractures in plastics, etc.). If one commits a reasonable
amount of time into reviewing for the oral exam, one will find the cases and questions to be fair
and logical, or at the very least that one will have a guess as to what the diagnosis is and can
answer accordingly.

As there are numerous sites in which one can complete their general surgery month and even
more for the different subspecialties. It is impractical to cover specifics for all sites here. Please
refer to the hospital site guide chapter for details regarding general information.
Each site will have a different meeting location on the first day, as determined by either the chief
resident or staff supervisor.
Teaching generally consists of on-call informal teaching from residents, teaching during
outpatient clinics, and the academic half-days (no noon rounds in surgery unlike in internal
medicine, meaning fewer free lunches!).
VGH has subdivided general surgery teams (ie. initial intake team, oncology surgery team, etc)
that each have different patient bases, schedules, and workloads. Students are assigned to one
team for the entire month.
Most sites are generally equivalent when it comes to surgical experience, although some students
have commented that VGH may have less OR time available for student involvement due to more
surgical residents and higher surgical consult volume from emergency compared to other sites.
The patients that present to each site tend to be generally similar, as there are only a few common
issues requiring surgical consultations from the emergency.
145

5 common general
surger y conditions to
know about:
5 things you can/will do while in the OR for surgeries

as a medical student:
1. appendicitis
1. retract. Do this well, or you wont be asked to do anything else

while in the OR...
2. small bowel obstruction
2. suturing (small laparoscopic incisions) or stapling. Practice

your 1 handed ties in advance!
3. gallstones
3. answer pagers. Residents, and even attendings, will really

appreciate you for this.
4. hernias
4. write the post-op note. Review this with the resident after
youve written it.
5. any abdominal malignancy
5. laparoscopic camera (if no residents around). Practice keeping

your hands steady for this one.

The surgery rotation provides the most operative experience students will have all year long and
should be fully taken advantage of. The opportunities to see and do these procedures will
gradually dwindle in ones medical career, unless they take the long, tortuous (or sometimes
torturous) path of surgery! So jump at the chance to hold that retractor, to follow that suture line,
and yes, even to transfer that patient post-surgery, as you might not get to do it again later on.
Admittedly, one can quickly become bored in general surgery. Once youve seen one
appendectomy, youve really seen them all (presuming youve seen both a laparoscopic and an
open one). By the 3rd iteration, one starts to feel like they can do the surgery themselves (not
recommended, no matter how confident you feel). However, iits precisely in this familiarity that
surgeons thrive in, as the more routine and straightforward an operation starts to be for the
operator, the less likely that surgical complications arise from inexperience.
Dont be that student who avoids the OR like the plague, no matter how distasteful you find
surgery to be. Youll inevitably have to be scrubbed in at some point, and unless youre keen,
interested, and reliable, youll never get beyond the step where you hold the retractor for an hour
straight. Theres certainly lots to see, lots to get your hands into (not all of it pleasant), and lots
to learn. Do also take advantage of your selectives, as again, those are opportunities that may
never arise again in ones medical career.
146
Early (a.k.a. earliest) morning rounds can be grueling, especially if youre in track A or B with
surgery in the dark cold months of winter, but luckily, surgeons write (and expect students to
mimic) the most brief, succinct progress notes youll ever see. One particular attendings progress
note consists of writing doing well on the chart, followed by a squiggly line (his signature).
Although not something students could ever get away with, that doesnt mean our notes cant be
efficient either. Did you pee, did you poo, did you eat, did you pass gas, did you get up and
walk, yes? Good. Does it hurt or bleed anywhere, do you have a fever, no? Ok see you
tomorrow.
147
Emergency
Written by Leslie Anderson and Andy Chen, MD 2013

Emergency is a 4-week rotation which the majority of students absolutely love. Students will see
a wide variety of patients, get the opportunity to do procedures such as suturing, and even
possibly be involved in some life-and-death situations. One might even help to revive someone
with CPR!
The field of emergency spans a broad scope of knowledge and skills and requires certain
personality characteristics such as the ability to multitask and think or react quickly. Although
emergency department physicians (EDPs), like family doctors, must understand a little about a
lot in order to know how to treat and manage a new patient, they must also learn a very
specialized skill set related to acute resuscitation, critical care, and disaster management.
Emergency is a specialty in which triaging patients based on urgency is turned into an art, and
directly resolving or redirecting problems becomes second nature. There are few things that can
come through the doors that an EDP would not know how to handle, or even make them
nervous!

On average, most students will be scheduled for 17-18 shifts during the 4 weeks, and each shift
will usually be 8 to 10 hours long, depending on the hospital site, type and time of the shift (ex.
overnight shifts may be shorter than daytime shifts, acute care vs fast track, etc). The time of day
you start work will vary as well, with some shifts beginning early in the morning while others are
in the afternoon, and most people will work at least a few overnight shifts. In general, student
schedules will group a series of day shifts together, and a series of night shifts together, in order to
try and provide some sort of regular sleep cycle for students. However, students shouldnt be
surprised if they find themselves working 4 days followed by 3 nights with only a single day off in
between. There are also academic half days on Thursdays that students will attend, and along
with weekend shifts, students should expect to have roughly 6-7 days off only during the 4 weeks.
Despite the busy schedule, there is lots to see and do and thus many students dont find
themselves bored or overworked.

There is no traditional call shifts in emergency, as students are scheduled for shifts (some of
which may be overnight), and thus the schedule is pretty straightforward.
148

Students should bring their stethoscope, a pen, and snacks. Emphasis on the snacks. Emergency
can be very hectic and busy, and it may be difficult finding time to stop and eat a proper meal.
Hence, anything one can shove in their pocket becomes critical to surviving the shift. Other
items that come in handy includes a penlight, a small notebook to jot extra notes in, and a pocket
drug reference as well.

Most of the time students will write directly in the patients chart, but some people prefer having
a notebook handy to jot down what theyve seen for logging and studying purposes. Just ensure
one doesnt let this cause them to slow their work pace down.

Students will be provided with a core content manual on Medicol that they are expected to read
through and for most people, this is sufficient. The other reference that is highly recommended is
Toronto Notes. Depending on the person, NMS Emergency or Pocket Medicine will also work,
but often there wont be sufficient time or energy to read too many in-depth books.
Memorable Moments
One of the least rewarding realities of medicine is the inevitable
encounter with death. I will always remember the first patient I saw who
died. It was a cold December night when we brought her to the OR with
a growing uterine cancer. It had been a frustrating week getting
everything ready, one of the greatest setbacks being her refusal for blood
products. Understanding the risks involved in the surgery, she consented
to the surgery anyway. I will never forget my attending's change in facial
expression when he saw the friable cancer, bleeding profusely, more
advanced than we had thought. With an intraoperative hemoglobin of
19, we knew her chances were grim. I remember spending a few
moments to say goodbye as she lay lifeless in the recovery area. I reflect
on her case often, knowing that she suffered from depression, loneliness,
and a lack of social supports. One thing I have learned - make every
word count, because it may be the last words that they hear.
-Joseph Leung, MD2013
149

Raising a family or maintaining a
relationship while being at the beck and
call of your seniors is not easy. However,
by making family and relationships a
priority, I was able to find time.
Sometimes, this meant being inflexible
and telling your supervisor that while
you would love to stay and do the
disimpaction, you have a play date with
your kids. At other times, this means
being flexible and taking advantage of
opportunities that arise. By keeping
family and relationships at the forefront
of your mind, achieving a healthy
balance during clerkship is possible!

ROTATION
Students should read around their patients and ensure they review both the commonly
encountered problems (ex. angina, abdominal pain, migraines, decreased level of consciousness
etc.), as well as the life-threatening things that should never be missed (ex. meningitis, sepsis,
STEMI, AAA etc.). There will be an academic half day each week and these sessions cover
many crucial topics, thus they are worth going to.

Most commonly students will be asked for their differential diagnosis, and what investigations
should be ordered. They may also ask students to interpret x-rays and lab results, and will expect
a discussion regarding the management plan. Anything is fair game in emergency!

The range of what students actually end up doing will vary widely depending on the site and
which patients happen to come in during ones shifts, but students can expect the chance to do
suturing, fracture/dislocation reductions & casting, IVs (just ask the nurses), and possibly ABGs,
intubations, and CPR.

Students will see most of the emergency requirements and will also likely check off several of the
must-sees for internal medicine, psychiatry, and orthopedics, given the wide variety of conditions
that can walk through the door.

Students should ensure they read the many eXcellent files and resources available to them to
prepare for the exam (check with more senior medical students regarding which eXact files to
read, and where to find them). The core content manual is also mandatory reading during the
rotation, and provides much useful information for students to read and learn from. Although
this rotation can be busy, try to find time at home to study, as there will likely not be any time to
study while on shift.

The end-of-rotation exam is a computerized 50 question multiple choice exam, to be taken at the
LSC multipurpose lab at UBC on the last Friday of the rotation. If students have read through
all of the required and recommended material, they should have no problems passing the exam.
150

*To find out where to go on the first day, CHECK YOUR EMAIL for a message from the department. Listed is where
students have met on day one in the past.
Site
Here is where students have met on day

one in the past:
VGH You will have an orientation on the first day and
instructions will be e-mailed to you. For each
shift, you will either go to the acute side or the
treatment side (if youre on a float shift, you start
on the acute side) and find the doctor starting at
the same time you are. You will also work two
shifts at UBC Hospital, and you just show up and
ask the nurse at the desk who youll be working
with.
RCH/ Report to the Emergency Physician, with whom
Eagle you are scheduled to work, at the start of the shift
Ridge and they will orient you to the layout and to your
clinical role in the Department. It is also very
important that you report to Sherry Hubick in
Medical Education on your first day to complete
some minimal paperwork and to obtain a photo
ID, along with your orientation material.
Where can I store my

belongings?
No lockers are available, but you
can leave your stuff in the ER
staff room (just dont leave
anything too valuable!)
What kind of teaching or academic sessions

are there at this site?
The academic half days are held at VGH on
Thursdays. You also work one-on-one with your
preceptor and many of them are excellent teachers.
Lockers are available in the

Almost all Emergency Department teaching will be
residents lounge in the basement. done around individual cases that you see. Try to
think of a focused objective or two to bring up with
your attending during each shift to ensure that you
address all of the learning objectives during your
rotation. Clearly not every learner will do every
procedure listed, but you can at least talk about each
objective over the course of your rotation. Our
philosophy is that house staff are here for education
and experience, not strictly for work. We all enjoy
teaching, but patient care is our primary role. At
times we cannot teach as much as we would like to.
Despite these practical real world limitations, there
is still a lot to learn in this Department.
There are regular teaching rounds at RCH posted on
a green flyer in the EP's office and you are welcome
to attend any of these when not on duty. If the
Department is very quiet and there is a relevant
topic at noon rounds you could ask the EP you are
working with if you may attend.
Site
Here is where students have met on day

What kind of teaching or academic sessions
one in the past:
belongings?
are there at this site?
SPH You will receive an email before your rotation
There is a ED doctors lounge
While the academic half days are important, a large
indicating where to go on day one.
available to put things in, but
amount of learning is done on site. Make sure to be
students will need their passcard inquisitive as the staff that you work with are very
to access this room.
willing to teach.
Alternatively, students can also
drop their stuff off in the internal
medicine consult service room.
SMH The coordinator will meet with new incoming
There are lockers available for
The on-site teaching is clinically based and you have
students between the hours of 0745hrs and
students use on the 3rd floor of direct access to the staff for all your shifts. Most of
1400hrs to provide lockers, login information,
F building. You may use your
the teaching will be delivered as "pearls" (do not
hospital ID (still must wear UBC ID) and parking own locks; however, you must be expect any didactic sit down session). Ask lots of
information.
aware of the following: if a code questions, the staff love to teach. The academic
Meet the site leader or the designate at triage in black is called, you must remove sessions are at VGH on Thursdays.
the ED. You will be given the orientation time
your lock quickly otherwise may
when you receive your schedule. Most of the time be necessary to cut off. (locks are
you will do a shift after your orientation.
available from medical
Announce yourself to the triage RN, let them
education)
know whom you are meeting and they will be
called.
Richm You will meet a emerg doctor by the nursing
There is a locker room with small There is no formal teaching but physicians are very
ond
station in the acute care area. This doctor will
lockers available for students.
keen to teach around cases
give you a tour of the facility and let you know
There is also a staff lounge with a
where to go next
fridge and microwave
Peace Park in the lot to the west of emerg, head into
There are lockers for med
Theres only informal teaching during your shifts
Arch emergency and ask a nurse for the doctor.
students in the emergency
around cases. Not a pimp heavy location
department.
Mount Just show up in the ER and ask the nurse who the Doctor's room in the back.
Just whatever you go through with your preceptors.
St.
ER doc is. It's super
Good hands on small procedures (e.g. fracture
Jose ph small so there will be no way of getting lost.
reduction, hematoma blocks, casting, lacerations
etc.). Also, each ER doc will have different
preference for how you present. It can be useful to
jot down each doc's preference because some are
very different in style.
Site
VGH
Is this a good site for someone interested in this

specialty?
Yes. You are one-on-one with an emerg physician and you can
get a lot out of the rotation if you show interest
SPH
Yes, the ED is busy and you will encounter a large variety of

cases.
RCH/ We are one the busiest emergency departments in BC and in
Eagle Canada, seeing about 67,000 patients per year at the RCH site.
Ridge We have ~25 full-time specialty trained Emergency Physicians
who spend 2/3 of their time at RCH and 1/3 of their time at
Eagle Ridge Hospital (ERH). The nursing staff are very
experienced and are a valuable resource, if you listen to what
they have to say. We have LPN's and orderlies who do all our
casting and splinting who will be happy to teach you these
skills, if you ask.
SMH This is an excellent site for someone who wants to experience a
very busy full service ED and wants to see and learn as much as
possible. The great advantage of our site is that there is never
more than one learner per day in a section of the ED.
Richm Yes. You will be the only medical student at the hospital for the
ond
entire month meaning that you have priority access!
What are common problems patients at What is the call

this site have?
schedule like?
Abdo pain, chest pain, trauma. You wont see There arent full call
any children (since BCCH is so close) and
shifts, but students will
very few pregnant women (same reason with typically have 3 overnight
BCWH).
shifts from midnight to
8am, and 5 late night
shifts that end between 23am.
There are many IVDU and MRSA+ cases that
arrive at SPH, more than other hospitals.
We see a mixture of adult and pediatric
Rotation schedule: Your
patients.
rotation schedule should
be available a few weeks
before your rotation is to
start. You will work
approximately 4-5 shifts
per week; a mixture of
days, evenings, nights
and weekends.
SMH has the busiest ED in BC. We see a wide Rotation schedule: There
range of patients from pediatric to geriatric
are seventeen 8 to 9 hour
with problems spanning all specialties. The
shifts during the rotation.
only facet that is not covered well is "big"
Before the rotation starts
trauma. We do see "minor" trauma (which can you will be given an
sometimes turn out to be major) but the Royal opportunity to tell us of
Columbian Hospital is 10 minutes drive away any requests and these
and they are the designated trauma centre for are almost always
Fraser Health.
honored.
No trauma and few serious acute care
situations. The majority of cases are towards
the family practice end of the spectrum
(gastroenteritis, strains/sprains/fractures,
lacerations etc)
Site
Is this a good site for someone interested in this

specialty?
Peace Good preceptors, who are happy to have you there, low
Arch pressure, good mix of pathology and representative of
community EDs. All docs are CCFP so might not be the best
for getting Royal College reference letters.
Mount No. This has no night shifts and the volume is very small. The
St.
doctors are great to work with but most have little pull in the
Jose ph selection process at UBC. It's great if you are not interested in
ER though, and dont want to spend time overnight at the
hospital.
What are common problems patients at What is the call

this site have?
schedule like?
Mix of elderly and young to middle aged
adults plus children. Chest pain, weakness,
lots of ortho, gastro. You are given a lot of
independence in general.
Abdominal pain, rule out MI's, geriatric ER, No call (in the ER)
psyc stuff, no trauma.

5 conditions not to miss diagnosing
5 procedures to read on in advance, as you will

likely do them in the ED
1. MI
Although the classical description of heavy pressure chest
pain/discomfort with radiating pain to the left neck and arm
is hard to miss, MIs dont always present this way. Instead,
one might see pains to the back or abdomen, and often
women present differently than men typically do. If theres
ever a suspicion of an MI, its worth getting an ECG and
troponins to be sure.
1. Suturing
Lacerations, lacerations, lacerations. In no other rotation
will students get more opportunity to practice their suturing
skills (surgery inclusive). Luckily, students usually wont
have an attending/resident watching over their shoulder,
presuming they demonstrate they are familiar and
competent with suturing techniques (having pre-read and
all!).
2. Stroke
A hemorrhagic stroke can be rapidly life-threatening, and
also be contraindicated for certain stroke treatment
protocols. In any case of acute neurological or behavioural
deficit/change, especially in the elderly, one should
investigate to rule stroke out urgently.
2. Fracture reduction and casting

Theres undoubtedly going to be more than 1 broken bone
coming through the doors, and one shouldnt be surprised to
see multiple on a single shift. Although some fractures are
too complicated to resolve in the ED and require an
orthopedic consult, many others are simple transverse
fractures that can be reduced and casted by ED doctors (and
students).
3. AAA
There is a vast differential for abdominal pain, and among
them includes abdominal aortic aneurysms, which poses a
very high mortality rate in cases of rupture. Patients with
complaints of pain in the abdomen should always be
palpated for a pulsatile mass, and if coupled with rapidly
decreasing blood pressure, should be assumed to be AAA
until it is otherwise ruled out.
3. Draining/aspirating f luid/pus/blood filled

cavities
If theres a body part one can think of, theres a way to fill it
with some sort of fluid, be it pus, blood, mucus or any other
body secretion. Fortunately, theres also almost always a
way to stick a needle in it and drain the cavity. If an
infection is suspected, dont forget to save the aspirate for
culture, and not just instinctively toss the entire needle in the
safety bin!
4. C-spine fracture/injur y
Whether its a high speed motor vehicle collision, high level
fall, or a impacting sport injury, one must always presume
there is a c-spine injury and protect the neck until it is ruled
out, either through x-ray or based on clinical findings. Even
if the patient is able to move their head on their own, this
does not guarantee no occult fracture has occurred.
4. Resuscitation:
CPR, airway management, and fluid replacement are all
procedures that require quick thinking and efficient action,
and students may be called upon to contribute in various
ways. It helps to not be caught off-guard like a deer in the
headlights.
5. GI Bleed
Sometimes innocuous, sometimes worrisome, sometimes
dire, depending on the amount, the timing, and the colour.
Many patients can have chronic occult GI bleeding, which
warrants further investigations, but not on an urgent basis.
However, it is those which have a severe amount of bright
red blood that persists that requires an immediate
consultation from the GI service, especially if the patient is
on a blood thinner.
5. Disimpaction:
Although not commonly seen, it does come up, and is
renowned for being one of the dirtiest procedures in the field
of emergency. Whether one wants to encounter the need to
perform this procedure or not highly depends on if they had
just eaten...

Emergency isnt simply a triage and referral service, redirecting any and all comers to the
appropriate specialist. They are in themselves a specialist of managing acute problems, ensuring
appropriate treatment or consultation is provided for all diseases and conditions, and of course,
saving peoples lives in life-threatening emergencies. As a rotation, you will find a large amount
of enjoyment, knowledge, and satisfaction in completing each shift, despite the longer hours of
non-stop work (time passes faster when theres stuff to do!). Certainly there will be many cases
that one has no idea how to diagnose or treat, but it is in these where the most learning is to be
gained. Furthermore, youll develop your skills in multitasking like never before, and youll be
surprised how much your short-term memory can store when you need to track 4 patients at the
same time! Whether you have this rotation at the beginning, middle or end of your year, theres
much to see, do, and like!
157
Anesthesia
Written by Serge Makarenko, MD 2013

Anesthesia is a 2 week long rotation coupled with orthopedics, and is generally a relaxed and
enjoyable learning experience. The discipline is focused on the principles of physiology and
pharmacology, and involves a large hands-on component through the administration of IV and
inhalational anesthetics and other drugs. By the end of the rotation, students should expect to
have had some practice and experience with tracheal intubations, laryngeal mask airway
insertions, and IV placements. Students should also become familiar with the use of various
induction agents and analgesics.

The majority of the 2 weeks of anesthesia will be at the assigned hospital site, with the exception
of 1 day at BCWH and 1 day at BCCH for maternity and pediatric anesthesia, respectively.
Students may also spend 1 day on the acute pain service or anesthesia consult service at their
local site. There are occasional lunchtime seminars/teaching sessions with residents, but these
are site-specific. Best of all, there are no morning rounds or call for anesthesia!
The typical day usually spans from 7:30 to anytime in the afternoon, depending on the OR start
time and how many surgeries are on the slate. Students typically are assigned a specific OR or
anesthesiologist for the day, and are expected to show up in the morning early, check-in with the
anesthesiologist, and usually see the first patient in the pre-op waiting room so that the doctor has
time to set-up their anesthesiology cart.
Throughout the day students will be participating in the pre-op anesthetic history/physical exam
(either performing, or assisting), anesthetic induction in the OR (see procedures section below),
monitoring throughout the case (and getting pimped at the same time), and then extubation and
post-operative assessment and care.
Once the patient is asleep during the operation, students will have lots of time for one-on-one
teaching with their attending and often will be allowed to go for a coffee or study break while the
case is happening. Depending on the length of the surgery, this break can be anywhere from 15
minutes to an hour!
Most OR slates are usually scheduled until 3 to 4 pm in the afternoon, but often the supervising
anesthesiologists will let the student go early after the last patient of the day has been induced, as
there is less learning opportunities remaining after that, and there has already been plenty of
teaching by that point of the day already.
158

As previously stated, there are no call shifts scheduled for this rotation. However, for students
particularly keen or interested in anesthesiology, it may be possible to talk to the site
director/supervisor and arrange for additional or replacement shifts to span the overnight period.

Stethoscope, a notepad or scrap paper for some note-taking, and a pen. Dont bring a bag into
the OR as there usually wont be a place to put it, and there would also be concerns regarding
sterility and sanitation. Also bring in some kind of reading material, either in paper or electronic
format, as there may be lots of downtime for reading on the computers in the OR. Finally, dont
forget to carry all evaluation forms and a daily log! After each day, students will need their
anesthesiologist to fill out an evaluation, and also sign a schedule log, as these will need to be
submitted at the end of the rotation to pass!

Pen and paper always works well, or if one prefers, with a smartphone (but be careful with this,
as sometimes staff/patients can assume one is texting when one is actually taking notes). Write
down patients/cases seen through the day, but in general there isnt much information that needs
to be tracked. Take the anesthesia consult sheet after assessing a patient in pre-op holding, as itll
serve as a reference sheet when presenting a patient to the anesthesiologist.

Anesthesia for Medical Students (from 1999, aka the Grey Book), although a little dated, does a
great job in covering the necessary major concepts and prepares students well for the exam.
Toronto Notes are also very useful for a quick summary of anesthesiology. Students will receive
a document about pediatric anesthesia, which is helpful to read prior to their day at BCCH.
There are also online modules provided that are helpful as an early orientation to anesthesiology,
and some doctors may ask questions in relation to those as well! NMS was generally not found
to be that helpful despite the recommendations, due to it having more detail than necessary for
student purposes.

ROTATION
Students should do the 6 (and increasing number of) modules available online on MEDICOL to
get a general sense of topic areas. Then, each day, students should choose a topic from the
objectives to cover with staff throughout the day. Memorizing common drugs (ie. propofol,
rocuronium, etc.) and dosages also goes a long way when in discussion with attendings. Dont
be afraid to ask questions throughout the induction process, or request to help or perform various
tasks for hands-on learning and practice.
159

Vancouver is a fantastic place to study because we are so close to many great outdoor activities. It is
unfortunate that many students believe that the pale tan from the hospital fluorescent lights is a sign
of commitment. Because I love the outdoors, I made a point of hiking, skiing, paddling or just
walking on my days off. Was I sacrificing study time? Of course not because I was that much more
excited to sit down with my books after doing something that I really enjoy.

There is a large focus on pharmacology and cardiac/respiratory physiology. Mechanisms of
action/dosages/pharmacology of common anesthetic agents are all fair game to be asked about,
but students shouldnt feel like they must know everything down to the letter. Hypothetical
scenarios (ex. what to do if a patient desaturates, if BP goes down, if there is excessive blood loss,
etc) may be posed by the anesthesiologist as well. Anatomy of the airway or spine is also
commonly discussed in the context of intubations and epidural/spinal anesthetics.
Maternal/pediatric anesthesia is only discussed with relevant patients at BCWH/Childrens,
unless one happens to be in an OR where c-sections or pediatric surgeries are taking place, which
may happen if in a community hospital.

Anesthesia will likely be the most hands on rotation throughout the year, and there will be
something to do for every single patient that comes through the OR. Procedures that students
should expect to get the chance to assist with/perform include:
Airway management procedures
Anesthesia induction procedures
manual bag/mask ventilation of a patient for IV insertions (peripheral or possibly central lines)
pre-oxygenation or assisted ventilation
endotracheal tube (ETT) placements
monitoring equipment set-up
laryngeal mask airway (LMA) insertions
spinal/epidural anesthetic delivery
extubations post-operatively
administering IV or inhalational drugs
tracheotomies (in rare emergencies)
monitoring/documenting patient status
160

Follow the objectives provided at the start of the rotation, and students should be able to
complete all the must-sees and must-dos for the rotation (most of which is outlined above).
Many of these skills will be found valuable throughout the rest of students medical training
careers, including intubations (ER), spinals/epidurals (ObsGyn, ortho), and knowledge of
cardiac/respiratory physiology (internal, surgery).

As stated above, read the textbook Anesthesia for Medical Students and the Toronto Notes, and
do the modules, in order to gain a broad scope of knowledge and understanding. Also, there are
many eXcellent files and resources available for preparing and knowing the kinds of questions
that will be on the exam, but students should be aware that not all of the exam will be covered by
only these files. Thus students should read eXtra files and resources too, on topics such as
maternal and pediatric anesthesiology.

There is only one exam for anesthesia, consisting of 50 multiple choice questions in an electronic
quiz format, with an hour to complete it. The exam will be in conjunction with orthopedics
(another 50 question exam) at the end of the combined month length (2 weeks anesthesia, 2
weeks ortho), and will take place at the LSC multipurpose lab at UBC on the last Friday.
Questions are fairly straightforward if students have been keeping up with the modules/text
reading, and should pose as no surprise to students who have adequately prepared.
161

Site
Here is where students have met on

day one in the past:
Where can I store my belongings?
VGH
You will receive an email prior to your

roation with instructions on where to
report
You can take a small bag with your

valuables into the OR. Your clothes can
be kept in the OR change room
SPH
The day before your shift, go to the

anesthesia office in the OR right when you
exit the change rooms. Ask the nurse for
the OR schedule. Your name will appear
next to the anesthesiologist that you will be
working with that day in addition to the
OR room number and case description.
Inside the OR there is a nurses lounge

with room to store your belongings, a
fridge and a microwave. There is no
secure storage so bring all your valuables
with you. It is alright to take a small bag
into the OR with you.
RCH
Each morning, go to the anesthesia office

in the OR right when you exit the change
rooms. On the bulletin boards, there
should be a student schedule posted listing
which anesthesiologist students are
assigned to for the day, which can be crossmatched to the slate to figure out where
exactly to go and who the first patient of
the day is.
There are occasionally empty lockers in

the change room which you can store
your stuff (make sure it doesnt belong to
anyone else first!), or you can leave your
stuff in the anesthesia office (but carry
your valuables with you in your scrubs
pockets).
LGH
The OR lounge on the 2nd floor. You need

to call the ID office ahead of time to have
access to the lounge added to your
Vancouver Coastal Health ID.
You can request a locker in the doctors

lounge, or just leave your bag/coat (keep
valuables in your pocket!) in a corner of
the OR locker room.
RGH
The OR. You will be directed to the

The OR change room is the best place to
anesthesia office where you can follow staff leave your stuff, but carry your valuables
around for the day.
with you.
BCCH
Go into the OR on the main floor and ask

the nurse at the desk where youre
supposed to be (usually the dental OR)
162
There are locker rooms on the 2nd floor

that should have a free locker to use.
Otherwise, you can leave your bag in the
corner of the OR locker room or in an
open locker.
BCW
Page the anesthesiologist for the day to

The OR change room is the best place to
meet up either in the OR, at the first floor
leave your stuff, but carry your valuables
nursing station, or in the anesthesiologist
with you.
offices, in order to be oriented and assigned
to an OR.
Kelowna On your first day, you should show up at

the undergrad office.
Leave your stuff in the OR change room,

but carry valuables with you.
Ver non
Go to the OR reception desk on your first

day.
Belongings can go in lockers in the OR

change room (code 2415*), but students
require their own lock.
Terrace
Head to the OR directly to meet the

anesthesiologist for the day.
Leave your junk in your locker. There

isnt much room in the OR with two
people at the machine and you dont
want your stuff tripping surgeons.
163
What kind of teaching or academic sessions are there at this site?

Regardless of which site students are at, all are similar in the sense that the majority of
teaching is in a 1 on 1 setting with the assigned anesthesiologist. Thus the quality and
amount of education provided is highly variable depending on staff, but students should
expect this to balance out across all sites and receive an equal opportunity to learn and
practice procedures. There are few residents at most sites (from 0-3), and although students
may work with and be taught by residents, there is likely to be minimal regular interaction
with them. Only some sites have academic sessions, and these usually only occur during 12 mornings/lunch times of the month.
Is this a good site for someone interested in this specialty?

All the sites provide ample opportunity to practice and learn skills and procedures in
anesthesia, and are well suited for anyone interested in the specialty. Although larger
centers may be busier and have less time in between cases to teach and learn from ones
anesthesiologist, they do offer more opportunities to perform procedures. Smaller centers
generally have no other students or residents around, and thus provide more opportunity to
assist or perform all types of procedures. Regardless of where students are placed, all are
generally very happy with their rotation and gain a large amount of knowledge by the end
of their 2 weeks.
What are common problems patients at this site have?

In general, every site will have a good mix of patient cases, and the site director will do
their best to assign a variety of surgical specialties to students in order for them to see
varying aspects and procedures in anesthesia. Students will receive much learning and
practice in spinal/epidural anesthetics during their maternity day(s), have an opportunity to
place IVs in children during their pediatric day(s), and should be able to see both short and
long surgical inductions in both healthy and highly comorbid patients. There should also
be ample opportunity to observe how to manage patients with difficult airways and obesity
at every site. Thus students should not be concerned about missing out on certain aspects
of anesthesia based on their location, as all are quite equal.

5 As of anesthesia
5 components of airway assessment
1. Analgesia: patients should experience no

pain throughout the surgery, and have
controlled pain afterwards
1. mouth opening: should be able to put 2-3

fingerbreadths into the mouth when patient opens it
as wide as they can
2. Amnesia: patients should have no

memory of the surgery itself
2. thyromental distance (TMD): should have at least

3 fingerbreadths of width between the top of the
thyroid and the bottom of the mandible
3. Anxiolysis: patients should be calmed

before and after the surgery
3. prognath: should be able to put their mandible

out so their lower teeth are in front of their upper
teeth
4. Akinesis: patients should be immobile

and have relaxed musculature
4. Mallampati score (class I to IV): with their mouth

open, how much of the uvula and posterior
pharynx can be seen?
5. Autonomic control: patients should have

a stable heart and respiratory rate
5. dentition: does the patient have any

loose/capped/false teeth, or another dental issue
that is an aspiration risk?

A common joke about anesthesiologists is to talk about the ABCs of the specialty: airway,
billing, coffee. Although there is some truth in this, (there is lots of downtime to get coffee and
operation billing codes from the surgeon are often sought), there is far more to the specialty.
Anesthesia is a complex balance between knowledge of physiology and pharmacology, with
applications of many hands-on procedures that require high dexterity. Although rarely seen in
action, they need to be able to think, plan, and act rapidly, should the need arise. But luckily,
good anesthesiology means that enough preparation and anticipation has been performed so that
patients remain stable throughout the entire procedure, and the doctors are free to read, surf the
web, and manage their stock portfolios for hours in a day.
Many students thoroughly enjoy their anesthesia rotation, as there is much to learn and do. It is
an exciting specialty, which often converts students into this career path after they have
experienced it. Regardless of ones interests, the skills gained on this rotation are fully applicable
to a variety of settings, and serve well to allow students to become reliable airway managers in
the future. As one RCH anesthesiologist has put it, if you dont learn how to properly bag a
patient by the end of this rotation, then weve failed as your preceptors. Also, if you cant bag a
patient, Im not letting you even touch an intubation tube, let alone try to insert one...
164
Or thopedics
Written by Ben Jong, MD 2013

Orthopedics is a 2 week long rotation coupled with Anesthesia, and consists of an even mix of
both clinic and OR time. The specialty has been described as applied anatomy, and certainly
students should expect to relearn much of their MSK block knowledge from 2nd year, including
muscle and bone nomenclature, as well as physical examination skills for musculoskeletal
injuries. There are a variety of patients, with both acute and chronic problems, that students can
expect to see, and subsequently learn from the principles of management for fractures (often
denoted as a # sign), tears, and various other injuries.

The student schedules are variable, and are dependent on the rotation site. In most locations,
students should expect to start their day early around 7am in order to round on surgical patients,
or to receive morning teaching. This is then followed by either a clinic or an OR day with various
orthopedic surgeons, some of whom may have specific specializations focussing on only one area
of the body (ex. wrist and forearm, lower leg and foot, etc). The clinics are very busy, and
students will encounter many cases at a very fast pace. The day ends at variable hours, but
usually students should be finished by 5pm. Depending on the site, students may also be
assigned time in the casting clinic, in a pediatric clinic, or emergency consults.

Again, call shifts depend on the site location. Some hospitals, such as RCH, do not require
students to complete call, unless they desire to do so. When call does occur, it is in-house, and
students could be awake through the night seeing emergency consults with the orthopedics
resident, or sleeping soundly through the night, depending on the variable volume at each site.
Call typically lasts until the next morning and students will be released from duties once rounds
have been completed on patients.

For days when students are going to be in a clinic, they should bring the usuals: white coat,
paper/pen, stethoscope in the odd event that one is asked to do some pre-op work-up on
someone (listening quickly to heart and lungs, vitals). Students can leave the stethoscope in a bag
or pocket, though. A pocket physical examination reference book/guide is also quite helpful to
look up specific musculoskeletal tests. An alternative is a smartphone with internet access. Sites
such as www.orthobullets.com or http://toporthoapps.com/ are great resources students can try
and see if they like.
165
For OR days, be sure to bring student ID cards to access the OR with (assuming ones ID card
has been set up already to give access to the OR!).

Pen and paper is the simplest method. Most sites dont expect students to take care of a lot of
ward management, so nothing fancier is required.

The required textbook Essentials of Musculoskeletal Care (available online at Stat!Ref) is
excellent, but some may not find it particularly useful in the orthopedic clinic or OR, as its
focused more towards primary care musculoskeletal injuries and management, rather than
surgical management and fracture healing. Instead, its likely more useful for students in the
clinic/OR to review their human anatomy and fracture types/patterns. Studying past anatomy
and musculoskeletal block notes from second year is a good bet. However, students should still
work through the assigned readings from the required textbook, as this will be examinable
material.

ROTATION
Students should study around their cases when they go home, and after trying to find out what
the next day looks like (ie. in an upper or lower extremity clinic, in the OR, etc), reading
appropriately in advance. For example, knowing about common upper extremity fractures is a
pretty good idea before going into an upper extremity clinic.
Memorable Moments
Orthopeadics was my first surgical rotation and on
my first day on the OR, I discovered a number of
unexpected procedures:
1. The choice of music is as important as the
choice of surgical tool
2. Be as prepared to talk about last nights
hockey game as you are to describe the
anatomy of the hip
3. Have a walk through Home Depot before the
rotation because that might also be a topic of
discussion
The bigger the power tool used in the surgery, the
more fun it is!
166

Sleep. Many years ago, it was decided that entrusting
students with health and life of a patient is too simple a
task. Therefore, we now have to do it while sleep deprived!
Unfortunately, this leads to nasty consequences for your
health, the health of your patients and your ability to learn.
Make sleep a priority. At home, I made sure that I was well
organized so that there was little to do to prepare for the
following day. This allowed me to clock around 7 hours.
And when I couldnt get this much sleep, I would often find
a quiet place during the day for a nap. During call shifts, I
would nap in the afternoon when it was quiet to make sure
that I had a little sleep under my belt heading into the
evening.

Doctors tend to ask questions about anatomy, as thats what we can reliably be expected to know
at our level. They may also ask about subjects such as osteoarthritis or other very common
orthopedic conditions students should have seen already or at least heard of (ex. distal radius
fractures, ganglion cysts, etc).
Of course, students should also know how to describe a fracture. Elements include location,
intra- vs extra-articular, type (transverse, spiral, oblique, comminuted), open vs. closed,
displacement, etc. (see The List below). To go the extra mile:
Know some classifications (ex. AO/Weber Ankle Fracture classification)
Know some rules/guidelines (ex. Ottawa Ankle Rules)
DONT just blurt out eponyms. Anyone can blurt out Colles Fracture! it takes at least
a little more thought to say, This is a fracture of the distal radius with the distal fragment
displaced and angulated dorsally with respect to the posterior fragment. This is also known
as a Colles fracture.
DONT assume that all attendings want the above. Some of them really do just want
Colles fracture, though most do want to know one is aware of what the characteristics
are.

Typically medical students will be allowed to do some suturing, although the experience varies
depending on the attending physician and the particular situation. Some students have been given
the opportunity to put screws or K-wires into bones, while others have helped prep and strip
tendon grafts. In cast clinics, students can help put casts on, remove pins, take out staples, etc but
they might have to ask to do these things since, as in many places, an RN or cast technician does
these procedures instead of the doctor. The key thing here is to be keen and enthusiastic, but not
pushy/whiny/annoying. Be someone theyre happy to work with, and the chance to do
procedures will come up.

Students should be able to check off assisting at major surgery, casting, splint application, and
suturing with surgical knots. They should also expect to see a variety of fractures and tears in all
areas of the body, as well as corticosteroid injections into various joints.
167

Due to recent changes in the orthopedics department and a new Orthopedics Director of
Undergraduate Education being appointed, the previously established exam has been revised,
and as a result there has been some confusion as to what to study. Rather than examining from
the 72 patient cases document provided to students, the department has now shifted to using the
assigned readings from The Essentials of Musculoskeletal Care as the basis for the exam
questions. Students do well by completing these readings, as well as studying from Toronto
Notes or other review book. The Wheeless textbook online
(http://www.wheelessonline.com/) is also a great reference for more details on orthopedic
condtions if other books are not comprehensive enough. The patient cases document from past
years, however, also serves as a great read for those interested in orthopedics, as it is more directly
relevant to what students will see in the clinic, OR, and emergency.

There is only one exam for orthopedics, consisting of 50 multiple choice questions in an
electronic quiz format, with an hour of time to complete it. The exam will be in conjunction
with anesthesia (another 50 question exam) at the end of the combined month length (2 weeks
anesthesia, 2 weeks ortho), and will take place at the LSC multipurpose lab at UBC on the last
Friday. As stated, the exam questions are based on the assigned readings.

Site
To find out
where to go on
the first day,
CHECK YOUR
EMAIL for a
message from
the depar tment.
Here is where
students have
met on day one
in the past:
Where can I
store my
belongings?
168
SPH
RCH
Variable. Dr.
Medical Education
Stothers sends an
Office (Basement
email with your
Level at the Health
schedule just prior to Care Centre) at
your rotation.
0815, to receive an
orientation and tour
from Dr. Mike
Lemke.
Nothing available
either store in the
clinic, or carry your
valuables with you
into the OR
SMH
Report to Dr.
Richard
Schweigels office
(across the street
from the hospital)
at 0800.
LGH
E-mail Dr.
Adam Sidkys
office before
your rotation
starts. Email
provided prior
to rotation by
the program
administrator.
Lockers are available Lockers are

OR locker
in the basement near available in the
room.
the lounge and call medical education
rooms.
area.
RGH
Call Dr. Richard
Kendalls office
before the rotation
starts. Youll get an
email with the
contact
information. Note
that you need to set
up your security
pass as well.
Visitor lockers in
the change room.
Site
What kind of
teaching is done
at this site?
Is this a good
site to choose
for someone
interested in
this specialty?
What are
common
problems
patients at this
site have?
SPH
RCH
Typically the best
Morning teaching
teaching is done in rounds are helpful.
clinic. In the OR,
Otherwise, the
things are variable teaching is variable.
it depends on how Some students
talkative the
report good
preceptor is. This is teaching, others not
a busier centre, and so much.
sometimes it can be
difficult to get some
teaching moments.
It can be if youre
Again, quite
keen show that
variable.
youre interested, try
to take initiative
within your scope
(ex. get X-ray reqs
and fill them out
ahead of time when
appropriate)
Variety of patients At this location,
seen the two weeks youll see a lot of
are organized on the trauma as all the
basis of a different staff cover this. All
clinic or OR each
the staff are also
day, so you should subspecialized, so
get a good variety. you should get a
decent variety.
SMH
Morning rounds
on Friday morning
are great. Also,
there are no
residents and few
medical students
on service, so you
get a substantial
amount of face
time.
LGH
Teaching is
good, with a
healthy amount
of 1:1 time with
young
enthusiastic
orthopods. No
residents.
RGH
Teaching is pretty
good. Lots of 1:1
time with the
preceptor in both
clinic and the OR
as there are few
residents and
medical students to
compete with.
This rotation can

be a great
experience the
balance between
clinic and the
operating room is
50/50, and there
are consults to deal
with.
Lots of hip, knee,
and shoulder
problems.
Yes few
Yes lots of hands
residents means on and variety of
you can work as cases.
hard as you like
without needing
to compete for
face time with
the staff.
Good variety of Mostly elective
problems. Some surgeries, not much
trauma-specific trauma.
days.

5 elements of a fracture description
5 treatment modalities for fractures
1. Classification: closed vs compound,

hairline vs partial vs complete, simple vs
multiple vs comminuted vs avulsion,
transverse vs longitudinal vs oblique.
1. conservative management: a watch and wait

approach, in cases where healing is expected to occur
without intervention due to a non-displaced fracture
(ex. hairline #).
2. Location: which bone, and what part of

it? Does it involve an articular surface or
joint? Is it in one location or did forces
travel through bone to cause fractures
elsewhere?
2. soft fixation: bracing, slings, taping, etc can be used

to provide additional support for simple fractures,
often as a means of relieving pain or preventing the
segments from separating due to muscle contraction.
3. Angulation: is the axis of each bone

segment not in the same direction, and
which direction does the apex point?
3. rigid fixation: casts or splints can be used for more

restriction of motion to ensure primary bone healing
occurs.
169
4. Rotation: is there any component of spin

of the bone segments in the long axis? This
is difficult to tell on a plain x-ray, and thus
students shouldnt state there is rotation
based on this study alone, unless there is
very clear rotation (ex. spiral fracture).
4. external fixation: K-wires and external bars are

used to secure bone fragments/segments to each
other, and are inserted percutaneously without the
need to cut skin to expose the bone. These are then
removed after bone healing has occurred.
5. Translation: how shifted are the segments

from each other and in what plane? This
can be anywhere from 10% to >100%
displaced.
5. internal fixation: plates, nails, and screws are

secured across fractures onto the bone to ensure rigid
fixation after the skin and tissue has been surgically
exposed. Usually permanent, but there is an option
to remove these later on if desired.

Orthopedics has a stereotype of the brawny jock doctor associated with it, in which macho
humour is the norm and expectation. As with all stereotypes, whatever little truth it may have
initially been based on is now gone, and one can find orthopedic surgeons in all shapes, sizes, and
genders. It is a fast-paced specialty that offers many interesting experiences, and can be very
enjoyable for all students. In addition, it serves as a crucial review of anatomy that many may
have forgotten following 2nd year, and reinforces the importance of a strong knowledge base of
the musculoskeletal system (well all see at least one, if not multiple, cases of fractures in our
careers, regardless of which specialty youre in).
There is often also an presumption that orthopedics is a dead-end specialty with no job
opportunities. Although the current employment market has been stalled, this wont remain the
case indefinitely, as many of the senior orthopods will soon retire, albeit at a later age than
normally expected. Regardless of these details, there is still no short supply of orthopedic
residents and fellows, all of whom enter the specialty for a love and appreciation of the
musculoskeletal system. Regardless of if one likes orthopedics or not, it cant be denied that any
specialty in which asking for a mallet and chisel during surgery is not atypical is certainly a cool
and unique quality in itself!
170
Obstetrics and Gynaecology

Written by Jessica Fong, MD 2013

Obstetrics and gynaecology (obs/gyne) is a 6-week rotation and, depending on where students do
their rotation, the split between obstetrics and gynaecology can be distinct or integrated
throughout the 6 weeks. One of the weeks is a preceptor week during which students are
assigned to one obs/gyne physician and will spend the whole time with him/her (clinic, OR, and
call) more info on the preceptor week can be found below.
There are 6 locations to rank preference of and be assigned to:
BC Womens Hospital (BCWH) and VGH
Royal Columbian Hospital (RCH)
Richmond General Hospital (RGH)
Lions Gate Hospital (LGH)
Kelowna
Kamloops
This can be a very busy rotation! Babies come at all hours of the day or night and students can
be just as (or even more) sleep-deprived in this rotation than they are during CTU or general
surgery. However, most call shifts are 24 hrs in-house (from 8 am - 8 pm) and one always goes
home at 8 am (the residents do!). That being said, how busy students are on this rotation is very
dependent on how much they put into it. Because things tend to happen very quickly on this
service, residents and nurses may not have time to page students even if they are asked to! Most
will make an effort, but good communication between students and the
resident/preceptor/nursing staff, as well as consistent follow-up on patients, are both ways to
ensure involvement. This is especially important if students are rotating at one of the peripheral
sites (LGH, RCH, RGH) as staff are not as used to having medical students as at BCCH.

Each student will receive a detailed individualized schedule at the beginning of the rotation with
a nice mix of clinic and inpatient learning opportunities. Call shifts are approximately 1 in 6,
although not necessarily evenly distributed throughout the weeks.
If students are not on call, they will be spending time at various clinics (colposcopy, fertility,
midwifery, ultrasound) or in the OR.
171
During preceptor week, students will have the chance to work with one specific obs/gyne
doctor and follow them to their clinic/call/OR. Their evaluation over the course of this week
will make up a large part of ones overall clinical evaluation.
There are two academic half days per week, usually Tuesday and Thursday mornings with
lectures videoconferenced from BCWH to all of the satellite sites. Clinic hours are typically 8 am
- 5 pm, but should be checked ahead of time with the clinic office. Call shifts are 24 hours with
post-call days off.
Memorable Moments
On my first call shift for obstetrics, I had finally gone to bed after a busy
and crazy day, but was paged at 3 am with the news that a healthy
young mother was about to deliver her first baby. I headed down to
labour & delivery, excited that I was finally going to see a normal
vaginal birth. Things went well for the first while labour was
progressing quickly, the mom was doing a great job of pushing, and
everything seemed to be going smoothly. Finally, with another big
push, the head came out then nothing more happened.
Usually, the rest of the baby comes out quite quickly and easily once
the head is delivered, but not with this baby. The atmosphere in the
roomed became tense. Something was wrong. A nurse came over to
my side of the bed, and while I and a student nurse pushed the moms
knees to her chest, the nurse was pushing down on moms lower
abdomen. The obstetrician was holding on to the baby, trying to
maneuver her into a better position. Still nothing. An episotomy was
performed, despite the mom having no pain control on board. The
baby was still stuck. The mom was screaming in pain. The
obstetrician told us to turn the mom over onto all fours and then back
onto her back. Finally, the baby turned and came free and was rather
stunned, although with a bit of stimulation she started breathing and
was okay.
That day I learned about a complication of vaginal birth that I didnt
know existed shoulder dystocia, where the babys shoulder gets stuck
behind the moms pubic bone, which is an obstetrical emergency. I was
sorry that the family had to go through such a difficult birth, but
thankfully everyone was okay in the end and I learned something too!

Clerkship is stressful. Constant
evaluations, seemingly unrealistic
expectations and isolation are only a
few of the challenges. Medial students
are not only not immune to mental
illness but are susceptible because of
these factors. Conditions including
anxiety, depression, substance abuse,
eating disorders, insomnia among
others are more common among
medical students than you might expect.
Unfortunately, many students fail to
seek treatment resulting in a decreased
ability to learn, perform and take care
of patients. If you find yourself even
questioning whether you may be at less
than optimal health, there are many
places to reach out to including the
OSA, the Physician Health Program
and your family doctor. Taking the
necessary time to care for yourself is not
a failure. In fact, failing to take care of
yourself is only harming you career and
your patients.

There is slight variability depending on the site, but calls are typically 24 hours starting from 7 - 8
am. Students do get post-call days off. When on call for obstetrics, students will usually simply
stay around the ward and follow women through the course of their labour & delivery. Students
level of involvement will very much depend on personal initiative, so students should remember
to ask the nurses and/or preceptor to call for any patient issues.
172

Dress code will depend on where students are scheduled to work for the day. The usual business
casual +/- white coat/stethoscope is appropriate for clinic, while scrubs are best when on call.
Shoe covers are highly recommended if students are working on labour & delivery (amniotic
fluid and uterine blood spillage is the norm)! One should bring along some study material in case
there is a break and an opportunity to get some reading done. Snacks are also great for busy days
when students might not get a chance to grab lunch on time, as patients may need very frequent
and regular monitoring during labour.

Some students found it helpful to make some index cards that they could fill in for each patient
they were following. This is particularly beneficial for obstetrics, when one may be following
multiple women in active labour throughout the course of the day. Include details on each
patients GTPAL, EDD, GBS status, time of membrane rupture, contraction frequency, vaginal
exam findings, etc.

The faculty-recommended textbook for this rotation was Hacker and Moores Essentials of
Obstetrics & Gynecology, but some may find this to be a little too dense and detailed for their
needs. Instead, many students found Toronto Notes and the Blueprints or NMS books to be
adequate for exam preparation. The department will give students a link for uWise, a question
bank with lots of practice questions, which are very useful for review studying. Students also
liked Pretest and Lange Q&A as further preparation for the NBME.

ROTATION
Students should read through their review textbook or Toronto Notes when/if they get a quiet
moment on the wards. Study around the cases that are seen. As exam time nears, try going
through as many practice questions as possible. Looking over some of the SOGC guidelines can
also be useful for the ward.

Do expect to be quizzed regularly by doctors and residents, as there can be lots of spare time in
between checking up on labouring patients. Most quizzing will be centered around pregnancy
conditions and risks, as well as the process and management of delivery. In the OR, questions
regarding anatomy and function should be expected as well. Common questions to expect (and
thus to know well) are:
173
What are the stages of labour?
What is this structure (pelvic anatomy)?
Maternal complications of pregnancy gestational hypertension, gestational diabetes,

antepartum bleeding, postpartum hemorrhage, infections
Fetal complications of pregnancy small for gestational age, oligo/polyhydramnios, Rh

incompatibility, post-term pregnancy, miscarriages
Approach to amenorrhea, menorrhagia, etc.

There are a variety of procedures that students will have an opportunity to be involved with
throughout the rotation, both in labour and delivery, the OR, and the clinic. The amount of
opportunities to do this depend highly on the students initiative and motivation, and this begins
first with introducing ones self early on in the labour process to the patient and her partner, as
well as the nurse. The better they know the student, and can see he or she is reliable and caring,
the more theyll trust and allow the student to do procedures such as an internal exam, or
actually delivering the baby!
The expectation is that by the end of this rotation, students should be reasonably comfortable
with the management of an uncomplicated vaginal delivery. Most students had the chance to
perform a few vaginal deliveries on their own over the course of the rotation. There should be
ample opportunity to assist in or even personally perform the delivery of placentas, suturing of
vaginal tears, insertion of foleys, and coaching the patient through contractions. During clinics,
students should be able to perform routine pregnancy physical exams (including fetal heart rate
assessments by dopplers), pap smears, STD and other infection swabs, biopsies, and possibly even
ultrasounds depending on the availability within the preceptors clinic office. There will also be
the chance to assist in C-sections and other procedures in the OR (hysterectomies, D&C, etc.).

Students should expect to complete most of the following while on call or during the scheduled
clinics. Any items missed should be reviewed independently, as they are important when it
comes to exam time.
Must-Dos
Vaginal delivery
Assist at C-section or minor/major surgery
Pelvic exam and Pap test
Urinary catheter insertion (female)
Assessment of labour: abdominal and
vaginal exams
Suturing of vaginal tears
174
Must-Sees
Antepartum assessment
Pregnancy complications
Labour & delivery
Postpartum assessment
Vaginal bleeding
Abdominal pain/pelvic mass

Reading over a review text of choice and doing some practice questions on uWise, Pretest or
Lange will help with preparation for the NBME. The OSCE is generally quite fair. Read around
cases and go over a general approach to common obs/gyne clinical conditions. Recurring OSCE
stations include the following topics (to which students should know the approach):
175
Routine prenatal care and prenatal screening/diagnostic tests
Gestational diabetes
Hypertension in pregnancy/HELLP syndrome
Intrauterine growth retardation
Postpartum hemorrhage
Ectopic pregnancy
Management and complications of multi-gestation pregnancy
Abnormal vaginal bleeding
Pelvic inflammatory disease (PID)
Contraception - both hormonal and non-hormonal options, in the form of oral

medications, intrauterine devices, or other methods
Pap smear schedule for follow-up if normal or abnormal, how are histological changes
classified, indication for colposcopy etc.
STIs and vaginal/cervical swabs (ex. gonorrhea, chlamydia, GBS)
Oncologic screening, diagnosis, and management of gynecological cancers
Urinary incontinence/ prolapse
Normal labour and delivery - show the cardinal signs on a model
Abdominal exam (including Leopolds maneuvers) shown on a model

The Obs/Gyne exams consist of an NBME and an OSCE/oral exam during the last week of the
rotation.
by a clinical question with (usually) 5 multiple choice selections. The questions are notably
longer reads than previously encountered multiple choice questions from 1st and 2nd year
medicine exams, and have been known to contain extraneous or excessive details not required to
answer the question. As such, it is recommended that examinees first glimpse what the question
is asking, then read quickly through the vignette before providing ones best answer and moving
on to the next question. Time can be lacking in the exam if every question is read meticulously
and overanalyzed!
The Obs/Gyne NBME is one of the more straightforward NBME exams one will write in third
year, and should not present any major surprises in terms of knowledge range and depth
required. The OSCE/oral exam consists of eight 10-minute stations, during each of which
students will discuss a clinical case with the examiner, reviewing the diagnostic approach and
management of obstetric/gynecologic complaints (as listed above).

BCWH/VGH
Where to go on the day one:
Obs/gyne is split into two 3-week blocks, with 3 weeks at BCWH for obstetrics, and 3 weeks of
gynaecology at VGH. The 1-week preceptorship is usually during the gynaecology block and will
replace one week of VGH service.
For obstetrics at BCWH, students will usually start the day at handover rounds in the staff lounge
at 0730, possibly followed by a thirty-minute case-based teaching session from the chief resident
and maternal fetal medicine doctors. For gynecology at VGH, handover rounds start at 0630 in
the 4C fishbowl, and also involve patient rounding.
Where to store your stuff:

Call rooms and lockers at BCWH are located at 2N49 (across from the entrance to the neonatal
nursery). At VGH they are located on Centennial Pavilion, 2nd floor.
176
Teaching done at this site:

Students will generally be most involved if they follow uncomplicated multiparous deliveries.
L&D and Cedar are good places for medical students since the deliveries there tend to be routine.
It is a good idea to try to pick up patients that are followed by GPs, although this may not always
be possible as Level 1 patients take precedence when ones help is needed. Many of the GPs are
very interested in teaching and allow medical students to really take part in the deliveries, more
so than with the on-call obstetricians. Information about each patient can also be obtained on the
computer, which summarizes the patients gravida, complications, and cervical dilation (at last
VE). Drop in on patients frequently to check how labour is progressing.
VGH details:
The volume of normal gynecology at VGH tends to be quite low. Rounds start at 0630, but most
mornings there are few patients to round on, although at times students may be asked to help
round on gyne-oncology patients. Following rounds, students will either go to clinic or to the
OR. Students are on call with a resident (who does home call) and there tends to be variable
volume so there will likely be ample opportunity for study.
Gyne-oncology OR days are mainly observational and unfortunately most of the time students
cannot scrub in as much of it is laparoscopic and there are always residents and fellows around.
UBC OR days are a bit better, as students tend to be able to scrub in, and can assist in
hysterectomies, etc. The gyne-oncology team is a very strong group, though students only get
one half day in the staff clinic.
The assignment of clinic varies from student to student: students may get one half day in the REI
clinic or none at all, two days in the OR, and possibly an afternoon in the maternal fetal medicine
clinic and two afternoons in the family practice maternity clinic. These clinics are all very
interesting and allow a lot of hands-on practice of clinical skills.
There are weekly grand rounds at both BCWH and VGH. At BCWH there are also weekly Fetal
Diagnostic Service Rounds and Perinatal/Neonatal Combined Rounds, but attendance is
voluntary. All students are required to prepare a 15-minute presentation on a selected obs/gyne
topic, which is presented to the rest of the group.
Good site for someone interested in Obs/Gyne?

If interested in obs/gyne, BCWH/VGH is a reasonable choice as students will be able to work
with the residents and see lots of high-risk obstetrics. However, it may be difficult to find
opportunities to interact with Obs/Gyne staff, and there may be less opportunity to perform
normal deliveries on ones own, as there are only 3 call shifts at BCWH (the other 3 are at VGH).
Having a variety of residents can be helpful for teaching, but as a result students may not be first
assist in the OR and there are also family practice residents around who need their share of
deliveries. In general, there is little time spent with a particular doctor except during the
preceptor week. A lot of the experience at BCW depends on which residents one is with. The
chief residents are great and really interested in teaching, but some residents do not really want or
care to have medical students around. Call shifts are not always very structured and students
really have to be proactive or they can finish a shift without having seen anything.
177
Common patient problems:

Students will see a nice range of both uncomplicated and high-risk pregnancies at BCWH. The
patient volume in gynecology can be low, but one will get a chance to see some interesting gyneoncology cases.
Richmond
Where to go on day one:
Students will get a site tour and orientation from the DSSL (Dr. Laura Heslip) on the first day.
As this is a community hospital, morning rounds are not as formal as at BCWH/VGH, and
students are generally not required to attend morning handover as the staff tend to do this with
each other through phone or email. Just show up at the birth centre or clinic as scheduled, and
be prepared to learn!

Students can store their belongings in the lockers by the call rooms or in the changeroom beside
the birth centre (3rd floor).
The volume at Richmond is more variable, with some nights being very busy and others being
very slow. Showing interest and initiative is key to a good rotation here. The docs will give
students a lot of hands-on experience if they want to be involved and nurses may call students if
they are keen (but dont count on it).
Students will spend a lot of time at the Noakes Clinic (RGH Maternity Care Clinic run by GPs)
where they will get good 1:1 teaching. The nurses are also an invaluable educational resource in
teaching vaginal exams and fetal monitoring. It helps to prompt the docs and nurses with
questions if students want them to teach something.
Few gynecology cases come through the Emergency when students are on call so most of the
gyne experience will be gained during preceptor week and during surgeries.
Dr. Heslip arranges two afternoons of organized teaching for the students at this site. Usually
this will involve a couple of students preparing a short presentation on an obs/gyne topic of their
choice and presenting it to Dr. Heslip and the other students.

Students have generally enjoyed their time at Richmond for this rotation. Because it is a smaller
centre, students will primarily see uncomplicated pregnancies and deliveries. The volume of
gynecology is quite low so students will need to study this material on their own for exam
preparation. That being said, there are usually no residents at Richmond (perhaps the occasional
family practice resident), so as the only learners around students can get a lot of one-on-one
teaching from staff.
Normal pregnancy and labour/delivery, vaginal bleeding, ectopic pregnancy.
178
Lions Gate
Students will get an orientation on their first day at the labour & delivery ward.

There are lockers available on the ward.
The workload during calls tends to fluctuate. The rotation is designed as a mix of obs and gyne
throughout the entire 6 weeks. The schedule is organized to include approximately two mornings
or two afternoons at the Lions Gate Maternity Clinic (run by GPs), two OR days, one afternoon
at a midwifery clinic, one week with a single preceptor and on-call duties (usually 1 in 4). There
are also the other clinics (infertility, gyne-onc, maternal fetal medicine), which the rest of the
students also rotate through.
The Maternity Clinic will be a very helpful part of the rotation for most students as they see
patients and newborns on their own and perform prenatal histories, physical exams as well as
newborn examinations. The physicians at the clinic are all great. There is lots of hands-on
experience during call (which is almost always scheduled with ones preceptor), including
consultations in the ER or the wards, assisting at urgent Cesarean sections or other gynecological
surgeries as well as vaginal deliveries. The ER consults can range from 0 4 per call. Students
may not see a lot of gynecological conditions unless they have consults or are in a preceptors
office. Studying the common gynecological conditions on ones own would be important for the
OSCE and the NBME. All of the obstetricians at LGH are great to work with. Also learn from
the nurses! All of them are very experienced in managing patients in labour.
There are weekly teaching rounds with different attending staff, as well as informal student-tostudent and staff rounds presentations.

As with most community hospitals, students will see mostly uncomplicated pregnancies and
deliveries here. As the only learners (no residents), students will have lots of opportunity to be
involved with deliveries and acting as first assist in the OR.
Normal pregnancy and labour/delivery, ectopics, menorrhagia, amenorrhea.
Royal Columbian
Students will receive an orientation at labour & delivery on their first day.

There are lockers by the call rooms/lounge in the basement.
179

The 6-week experience combines obs and gyne, which keeps the days varied with options to
participate in deliveries, C-sections, or gyne surgeries such as hysterectomies. The environment is
very friendly and non-stressful, with most doctors being eager to teach. There are weekly
teaching rounds with staff.
Schedule at this site:
Students will be on-call with a resident and things can get pretty busy. Expect to arrive around 7
am and stay in hospital until 9 am the following day. Occasionally one can get as few as 2-4
hours of sleep but other times one might get lucky and sleep through the night. Days on-call are
flexible in terms of what one wants to do, but it's important for the student to be proactive and get
the nurses and unit-clerk to call for the deliveries, otherwise it's easy to miss deliveries during the
evening and night.
Good site for someone interested in obs/gyne?
RCH is a large centre with high patient volume. Students will tend to see more obstetrics than
gynecology at this site. There are more learners around than at the community hospitals, but if
students are keen to get hands-on experience, they should try to spend time with the GP patients,
as residents will usually get first dibs on the more complicated cases and C-sections. It's a great
hospital and a good chance to get hands-on experience.
Normal pregnancy and labour/delivery, vaginal bleeding.
180

5 aspects to describe on an inter nal exam
of the pregnant/labouring patient
5 aspects of a tocog raph to describe

to classify as a normal/abnormal
tracing
1. Cer vical dilation : how open is the cervix

(closed, 1-9 cm, or fully dilated), and at what rate
of dilation is it opening?
1. Baseline rate : 110-160 bpm is normal

(look for long relatively stable segments of
tracing that only flutter a little in rate)
2. Cer vical effacement : how thick is the cervix

(stated from 0-4 cm in length, NOT effacement
percentage, which can be confusing and variable in
patients)?
2. Variability: 6-25 bpm is normal

moderate variability, while less, more, or
sinusoidal for an extended period of time is
abnormal and concerning
3. Station: how far down is the foremost

presenting part in relation to the ischial spines
(from -3 to +3, but in practical use, should only
range from -2 to +2)?
3. Accelerations : > 2 accelerations with a

peak > 15 bpm for 15 seconds (in term) or >
10 bpm for 10 seconds (in pre-term) is
normal
4. Membranes : is the membrane still intact, felt

4. Decelerations : no decelerations or
as a bulging water balloon in the middle of the
occassional variable decelerations <30
dilated cervix (dont push too hard or itll rupture!)? seconds is considered normal. Long
variable or late decels are abnormal.
5. Presenting par t : if the membranes have
ruptured, feel for the fontanelles and sagittal suture
to determine the orientation of the head (left or
right OA/OP, or transverse)?
181
5. Stability : has this tracing remained

relatively the same over time, or have there
been any changes to its appearance or
characteristics recently? Is the nurse
concerned at all with the tracings stability?

Obstetrics and gynecology is one of the most unique rotations, and provides you with very
special opportunities to fully participate hands-on in patient care. Many students feel privileged
to be a part of the joyous occasion of birth, and the parents are often extremely appreciative of
the role students have played in their care. Although at times it can be messy (dont wear nice
shoes or clothes!), getting your hands dirty is the ONLY way to do obs/gyne. No learning will be
gained if students are not keen and proactive in this rotation.
Get involved in assessing women when they are admitted, or introduce yourself early on in the
labour process before the patient becomes too distracted and is in too much pain to acknowledge
your existence. Make sure to check in on them on a regular basis through the course of their
labour, and provide any reassurance or assistance they might require (this might even be
something as simple as a cool soaked towel for their forehead!). Nurses play a key role in
managing labour, so introduce yourself to the nurses taking care of your patients and ask them to
call you for any issues so that you can get involved, or when theyre planning to do an internal
exam so that you can observe or even practice. They are also a great source of knowledge and
experience to learn from. Remember, if neither the patient nor nurse knows who you are and
they are not comfortably acquainted to your presence in the room, you certainly wont even be
welcome to stay in the room come delivery time, let alone actually catch the baby!
Some pregnant women feel uncomfortable with having a male student in the room (there has
been the odd female student asked to leave as well!). Do not feel discouraged or offended if this
happens to you; it certainly isnt anything personal, simply that the patients comfort and
preference is the priority. There will be many future opportunities in which you will be
welcomed to participate. The best advice to increase the likelihood that a patient will allow you
to participate in her care is to try to meet the woman early in her labour (i.e. from admission if
possible) or to stick with either a family doc, resident, or obs/gyne and have them introduce you
as a part of the team. Also, when you initially meet the patient, make a conscious effort to be
warm and caring. Smile (but not in a creepy fashion), and dont rush the initial patient interview.
It is easy to forget to do this through 3 am-waning-caffeine-blood-level fatigue.
Although it may be true that many students have in mind a specialty in which they will rarely
encounter maternity patients and wont require this knowledge, that is no excuse to slack off or
put in a half-hearted effort. Yes, if you choose to, you can hide yourself in the background and
not be called for anything, but keep in mind that hands-on learning is a means to properly
prepare for the NBME and OSCE, and thus students should seek as much experience and
opportunity as possible. Be proactive, and therell be lots to see and do!
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Ophthalmology
Written by Sally Ke, MD 2014

Ophthalmology is a 1-week rotation and is interchangeable in the schedule with dermatology,
another 1 week rotation. The specialty focuses on the eye and includes various diseases and
conditions that affect vision such as cataracts and glaucoma. Students will rotate between
general and subspecialty clinics, and there may be an opportunity to observe ophthalmologic
surgeries as well. The week is mostly spent at VGH/Eye Care Centre, and students will see
outpatients that are usually otherwise healthy.

A typical day starts at 8am and ends between 4-5pm. Students are assigned to a different clinic
for each half-day and are expected to call in advance to confirm the start time or their attendance.
Clinics vary from student schedule to schedule, and can include the general clinics, the residents
clinic, or subspecialized clinics focused on glaucoma, the anterior chamber, or the retina.
Students will also have an afternoon in the suturing wet lab, in which they will have the
opportunity to practice tying microsutures (10-0 suture!) under microscope visualization on pig
eyeballs. There may also be an afternoon scheduled for students to observe cataract and
glaucoma surgeries in the OR. The week ends with the multiple choice exam on Friday
afternoon.
Memorable Moments
Medicine is full of fancy procedures designed to
help the doctor distinguish between health and
disease. There are at least a few that I am sure you
have found yourself trying to convince yourself that
you do in fact see the target. Observing the
tympanic membrane, noting Kerly B lines on CXR
and successfully finding the optic nerve on
fundoscopy are just a few examples. It was not until
my final day of my ophthalmology rotation that I
finally found the optic nerve and was I excited!
Thanks to the patience of a wonderful attending, I
now am confident in my ability to use that
expensive fundoscope!
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Clerkship can be lonely. Even in busy hospitals you may
find yourself without any medical students with whom to
share stories, advice, encouragement and frustration. This
can become very trying as often students feel as if they are
the only one that is putting up with an intense patient load
or negative feedback. If you can make time to get together
with your peers you can have a positive impact on all of
your experiences. But even saying hello in a busy ward
will help boost the morale of your friends. Community,
although seemingly absent from clerkship, is integral to your
success as a clerk.

There is no overnight call in ophthalmology scheduled for students. However, if students do not
have a clinic scheduled, they may be assigned to take calls during the daytime (although this is
rare and unlikely, as the residents dont generally have regular interaction or contact with
students).

Generally, students do not need to bring their own ophthalmoscope, as every clinic will have
these available. However, some preceptors expect you to bring your own in order to practice with
one youre familiar with, and this will be stated on the student schedule. Nonetheless, students
are able to pass the ophthalmology week without needing an ophthalmoscope of their own.
Beyond this, students should carry paper and pen with them as per usual, as well as multiple
copies of their evaluation forms and attendance sheet, and a copy of the mini-CEX evaluation.
After each clinic, students need their preceptors to sign their attendance sheet and fill out an
evaluation form, and these will be submitted to the program assistant on the 3rd floor of the Eye
Care Centre at the end of the week. Students should also bring their whitecoat, as preceptors
may wish them to wear it in the clinic setting.

Students have not found it necessary to keep track of patients in detail as they are generally
outpatients, and students do not attend the same clinic more than once.

The recommended textbook is Basic ophthalmology 9th ed by Richard Harper (2010). It is
available at the administration office in the Eye Care Centre and can be loaned out for the
duration of the rotation. Students will also be sent a file with links for various topics taken from
a CD. As it is only one week long, it is unlikely students will have time to read a full
ophthalmology textbook during this time, nor is this necessary.

ROTATION
Students may benefit from a quick review of material on eye anatomy and common conditions
such as cataracts and glaucoma prior to the start of the week to familiarize themselves with the
specialty. There is also more than adequate time to study in the evening regarding any new or
unique conditions encountered while in the clinic during the day.
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As the clinics can be busy, how much students are asked questions vary from preceptor to
preceptor. When this does occur however, expect questions such as:
Can you see the fundus? Describe what you do or do not see there.
Eye anatomy and methodical slit lamp exam.
The differential diagnoses for red eyes, inclusions on fluorescein exam, etc.
Relevant aspects of an eye disease history
How to measure and record visual acuity for distance and near vision, both with and
without correction and with pinhole where appropriate.
Examine pupillary response (direct, indirect, accommodation)

As ophthalmology is highly focused on the eye, there are essentially only 3 procedures students
will need to perform during their rotation:
Direct ophthalmoscope: examine the fundus to visualize the optic disc, macula, vessels, and any
abnormalities of the retina
Slit lamp: examine external eye structures (lids, lashes, and conjunctivae) and anterior segment
(cornea, anterior chamber, iris) for abnormalities
Vision testing: this can include visual acuity, extraocular eye movements, pupillary reflex, RAPD
testing, colour vision testing, peripheral field testing, etc.
Students will also get the opportunity to practice suturing on pig eyeballs with 10-0 filament
sutures under microscope visualization in the wet lab.

Students will obtain a Year 3 rotation procedure and patient encounters must see/do list, which
they must log on One45. By the end of the year, students must have performed 10
ophthalmoscopic examinations (direct) and 10 slit lamp examinations (this shouldnt be difficult
to complete). Students are also required to see 1 patient with amblyopia/strabismus and 1 patient
with cataracts.
Aside from the course requirements, what you see depends on the clinics assigned and your own
interest. You may be encounter: age-related macular degeneration, cataracts, conjunctivitis,
blepharitis, chalazion, hyphema, corneal foreign body or abrasion, diabetic eye checks, open
angle glaucoma, posterior vitreous detachment, retinal tears, preseptal or orbital cellulitis,
refractive errors, central serous retinopathy, and various other conditions.
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The best method of studying is to read and review the eXcellent files and study materials
available from past medical students (just ask your buddy!). In addition to reading this review file
as well as the recommended textbook, students can also read around various patient cases they
see in clinics using the reference book of their choice (Toronto Notes is always a good bet).

The exam is 100 multiple-choice questions in an hour (dont worry, the questions are shorter than
NBME questions!), and is written at the Eye Care Centre on the Friday afternoon of the rotation.
It is fairly straightforward, presuming students have read the eXcellent files and study resources
available from past medical students.
There is also a mini-CEx that should be completed sometime during the week, in which a doctor
needs to observe you operate a slit lamp and perform a direct ophthalmoscope exam in order to
evaluate you. Try to complete this as early in the week as possible, as some clinics are extremely
busy and the preceptor will not have time to conduct a students mini-CEX. The residents clinic
may be an ideal time to complete this, as it is generally less busy and the residents are always keen
to teach.
To find out where to go on the first day, CHECK YOUR EMAIL for a message from the
186
Site
VGH (All students are mainly at this site)
Here is where
students have met
on day one in the
past:
Go to the Eye Care Centre (ECC) for an instructional session with the
resident in the morning. There will usually then be an teaching session,
followed by an afternoon clinic. Normally, you are assigned to a clinic
each morning. If not, write down your pager/phone on the whiteboard
so the resident can call you if there is a consult.
Where can I store

my belongings?
If you are in the clinic, you can keep your belongings in the residents
lounge in section D of the ECC (no guarantees of security), in the clinic
office spaces itself, or an MSAC locker. If you are on call, carry your
belongings with you.
What kind of
teaching or
academic sessions
are there?
There is a useful and fun corneal suturing workshop. You also have
some lunch-time teaching with a resident. Many preceptors are also
excellent and happy to teach students.
Is this a good site

for someone
interested in this
specialty?
Since there is no student choice as to which site they will be at and this
rotation is only a week long, students interested in ophthalmology as a
future career must select more ophthalmology electives in 4th year. In
general though, this rotation will provide a good experience for any
student to learn and review their ophthalmology knowledge and skills.
Common patient
The common presenting problem depends on the clinic that you are in.
problems at this site You may be assigned to clinics in general ophthalmology, retina,
cornea, glaucoma, pediatrics, etc.

5 steps to direct ophthalmoscopy
5 steps to a slit lamp exam
1. Patient set-up:
- Ensure patient is sitting straight
- Adjust chair height so the patients eye level is
just below your shoulder height
- Have patient focus on distant spot on wall and
tell them to look ONLY at this point with BOTH
eyes (this is crucial, because if the patient moves
their gaze around, youll soon become dizzy and
disoriented!)
1.Patient set-up:
- Ensure the patient is sitting straight, and have
them place their chin on the support, with
their forehead against the strap
- Adjust the patients height, the slit lamp
tables height, and the slit lamp height so that
the patients eye level is at the black lines on
the vertical bars, and the eyepieces are roughly
at your eye level
2. Examiner set-up:
- Turn the room lights off, leaving only a dim light
source on directed away from the patient, or
leaving the door open
- Adjust the ophthalmoscopes light setting to the
desired setting (generally the mid-sized circle at
medium brightness is best to start). - Set the focus
dial to the appropriate +/- eye prescription,
depending on if the examiner is or isnt wearing
their glasses for the exam.
- Take a stable stance, bending yourself to bring
your eye to the patients eye level. Stabilize
yourself by grabbing onto the shoulder of the
patient or chair with your non-scope hand.
2. Slit-lamp set-up:
- Turn the room lights off and the slit lamp on
(the switch is usually on the edge of the near
side of the slit lamp platform)
- Unlock the slit lamp from its locked position
by unscrewing the securing device on the
horizontal bars, so that the slit lamp can slide
around on top of the platform
- Select the desired light colour (normal light
or the blue light), adjust the slit lamp width to
be only a few millimetres in thickness. The
vertical height should be ~2cm
- Adjust the viewing eyepieces so that the
interpupillary distance matches your eyes
- Slide the slit lamp into position in front of
one eye, and begin viewing the patients eye
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3. Approach:
- Look through the scope with the same eye as the
patients eye being examined. Orient your gaze so
the light is directed at the patients pupils.
- lean closer and closer in, at an 15 degree angle
on the temporal side, while continuing to focus on
the patients pupil
3. Exter nal str uctures:

- Examine the lids, lashes, and lacrima for
problems like inflammation (ex. blepharitis) or
other abnormalities (ex. ingrown lashes)
4. Orient:
- Once you can look into the patients pupil at the
back of the eye, search for landmarks such as
vessels, and trace them back to their source to find
the optic disc
4. Conjunctivae, Sclera, and Cor nea:

- Examine for redness, dilated or broken blood
vessels, jaundice, or epidermal damage (ex.
corneal abrasions)
5. Explore:
- Look around at other parts of the fundus to find
other landmarks, such as the macula. Observe the
main branches of the vessels for signs of nicking.
Also look for any other abnormal changes such as
papilledema or intraocular hemorrhaging.
5. Anterior chamber:
- Examine the iris, pupil, lens, and anterior
chamber for problems such as non-reactivity,
cataracts, other densities, bleeding (ex.
hyphema), or narrow angles

Ophthalmology is perhaps the most specialized of specialties that you will rotate through in your
third year. Much of the knowledge gained during this rotation wont arise or apply frequently in
other fields, and if they do, it would be expected that a referral to ophthalmology would be
required anyway, rather than resolving the problem within your own specialtys expertise.
However, this is not to say the learning and information of this rotation should be ignored,
neglected, or forgotten. Rather, as it may be the only focused experience within the realm of the
eye that students will get during their medical careers, they should ensure they spend the time to
truly comprehend the diagnosis and treatment of many common eye conditions such as cataracts
and glaucoma. Furthermore, strong skills in a direct ophthalmoscope exam is critical for
detecting signs of other diseases such as hypertension and diabetes, and thus the more practice
students can get during the rotation the better. They say the eyes are the windows to the soul, but
in medicine, perhaps theyre more windows to ones health!
188
Dermatology
Written by Aaron Gropper and Andy Chen, MD 2013

Dermatology is a 1 week rotation and is interchangeable in the schedule with opthalmology,
another 1 week rotation. It focuses on the skin and associated structures and encompasses
encounters with both very common skin conditions (ex. acne), as well as possibly rarer diseases
(ex. Steven-Johnson syndrome). Although it is short in length, it is very fast-paced and is
jammed with a multitude of clinics covering various areas of dermatology. It is a very enjoyable
rotation, and students will gain a key review of the integument block from 2nd year.

Most days start at 8am, but students will need to call each morning clinic the day before to
confirm the start time when the first patient is booked. Clinics are only a half day long, and in
the afternoon students can either expect to be at another clinic (confirm the start time in advance
as well), or on a dermatology consult call service. Afternoon clinics typically end around 4:30
but, again, this varies depending on when the last patient is scheduled. The dermatology resident
will release the student from consult call duties around 4:30pm.

There is no overnight call during this rotation. Students may, however, be asked to see hospital
consults during the day if they have no clinic scheduled. These can then be reviewed with the
resident or staff.

A pocket guide with dermatology pictures and information is helpful during the rotation.
Similarly, a smartphone with an app or internet access can be used as a reference source. As
always, a pen, paper and clipboard are essential. Students may also be expected to wear their
whitecoats during this rotation, depending on the preceptors preferences. Students should also
remember to have multiple copies of the evaluation form with them at all times, as they will
require one to be filled out by the preceptor after each clinic (more for attendance purposes than
anything else). These forms should then be submitted to the VGH resident at the end of the
week.
189
Memorable Moments
When I think of dermatology, I tend to envision rashes, lesions and
fancy cars. This is not what I got on my first consult in dermatology. It
was mid-morning at Saint Pauls Hospital when my resident asked me
to see a patient recently admitted to emerg. He was a patient in his
fourties with no fixed address and a history of drug and alcohol abuse.
On exam, his body was covered with excoriations and lichenification.
The rash was unlike anything I had seen in Fitzpatricks. After
discussing my findings with my resident, I was encouraged to check the
seems of his clothes because sometimes you can spot the eggs of scabies
in the seems. Upon insepection, I could not find any eggs but the
seems were crawling with live bugs.

I have a passion for the arts. There is
nothing more relaxing and rewarding
for me than to catch a play or a new
exhibit at one of our wonderful
museums. Clerkship is stressful. For
me, allowing myself to still indulge in
music, theater, artwork and the like is
an escape that helped me through
medical school.

As students are moving from clinic to clinic, they will not need to keep careful track of patient
details. Writing on and referring to the chart papers should be sufficient when reviewing with
staff. Students should ensure they have read the orientation package to learn how to take a
dermatological history and physical in order to write a proper consult.

The online UBC dermatology website and modules are a great resource. Students should also
read the provided reading materials (ex. The Fundamentals of Skin Disease Therapy), prior to
the start of the week. As this rotation is only a week long, there is unlikely to be sufficient time to
read full textbooks on dermatology. Instead, if students need to find pictures of dermatological
conditions to familiarize themselves with their appearance, there are useful derm atlases available
online:
http://dermatlas.med.jhmi.edu/der m/
http://dermis.multimedica.de/der misroot/en/home/index.htm )

ROTATION
Students should review common skin conditions prior to the start of the week (see The List
below). After each day, students can also study in more detail any conditions they encountered
in clinic during the day that they are less familiar with, or questions that arose from these cases.
By the end of the week, students should be knowledgeable on the majority of the common skin
conditions, and be familiar with many other less frequently seen dermatological diseases.
190

Students should be prepared to describe a lesion using appropriate dermatological terms (see The
List below), and to come up with a differential diagnosis based on the morphology and history
of the lesion. Although students arent usually expected to formulate a treatment/management
plan, they can often learn more by thinking about this themselves first, then presenting their ideas
to the preceptor during the discussion. Doctors may also ask students various details related to
common skin conditions (ex. whats the differentiating qualities between eczema and psoriasis?

As the clinics are fast-paced, students may not have much chance to perform any procedures,
even under supervision. If students are fortunate, they may be able to perform cryotherapy, skin
swabs, and skin biopsies.

Although there are no strict rules regarding what procedures students must do during the
rotation, they are expected to see most of the common skin conditions.

Review the online Medicol dermatology modules from 2nd year, and pay attention in clinics
during the week. Coupled with some brief review of the various eXcellent files and resources
available, there shouldnt be any issues as the exam is very straightforward.

The exam is available online as a 10 module quiz, each consisting of 5 questions for a total of
50. It can be completed any time during the week of the rotation, and is open book! It would be
surprising to anyone, including the faculty, if any student was to fail this exam...
To find out where to go on the first day, CHECK YOUR EMAIL for a message from the
Site
Vancouver General Hospital (VGH) and St. Pauls

Hospital (SPH)
Here is where students

have met on day one in
the past.
Students will have a clinic the first morning, and thus should have
called the previous week to confirm the start time.
191

belongings?
Students may be able to put their things in the dermatology library

on the 3rd floor of the skin care centre, although it isn't very secure.
Otherwise, they can just leave their bag wherever the doctor or
MOA says is ok in the clinic.
What kind of teaching

or academic sessions
are there?
There were some dermatology rounds and teaching sessions with

the resident at noon time. Topics vary from week to week, but are
generally interesting and useful for students to attend if possible.
Unfortunately food is not usually provided at these rounds.

this specialty?
Since there is no student choice as to which site they will be at and

this rotation is only a week long, students interested in dermatology
as a future career must select more dermatology electives in 4th
year. In general though, both VGH and SPH provide a good
experience for any student to learn and review their dermatology
knowledge and skills.
What are common

problems patients at
this site have?
The weeks experience and patient problems encountered varies

from student to student, as there are different schedules with
different clinics assigned. Some students may have various general
dermatology clinics, a BCCH pediatric clinic, a hair clinic, a rapid
access care clinic, a skin cancer clinic, a Mohs surgery clinic, or
any combination of these and more.

5 common derm
conditions
5 elements to describing a skin lesion
1. Acne : open/closed
comedones that are
inflammed; related to
Proprionibacterium
1. Primar y lesion :
macule/patch, papule/plaque, nodule/tumor, vesicle/bulla, pustule,
cyst, wheal, burrow, comedone, telangiectasia, petechiae/purpura
/ecchymosis, milium/milia, keloid/hypertrophic scar
2. Eczema: the rash that 2. Secondar y lesion/associated characteristics:

itches, and vice versa
scale, crust, excoriation, lichenification, maceration, fissure, erosion,
ulcer, alopecia, atrophy, Koebnerization, pathergy
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3. Ur ticaria/Hives : can
be allergic, drug related,
viral, or idiopathic; often
self-resolving
3. Appearance (colour, shape, texture) :

erythematous (red), violaceous (purple), pigmented (brown, black,
grey), variegated (multi-coloured), hypo/de-pigmented, yellow,
orange; margins (smooth/irregular, well/poorly demarcated),
polygonal, targetoid, umbilicated, verrucous
4. Psoriasis: scaly, welldemarcated, salmon-color

plaques
4. Configuration :
linear, annular (circular/ring-shaped), arcuate (curved), polycyclic,
reticulate, grouped, zosteriform/dermatomal
5. Alopecia areata :
patchy hair loss without
known cause
5. Location/Distribution :
body part, flexural/extensural surfaces, symmetry bilaterally,
localized/generalized, relation to worn objects/exposed skin

Dermatology is a short rotation, but offers much in the way of learning opportunities. The skin
is a critical organ in maintaining health and homeostasis, and any branch of medicine will have
some relation to the integument. Although most of the patients you will encounter will have
common skin conditions with a relatively standardized treatment protocol, there are always small
nuances to the care and management that can only be appreciated through observation and
discussion with a dermatologist. The rotation also presents a chance for you to see very unique
skin conditions. During these opportunities, you should carefully observe and learn, as you may
never encounter them again. Regardless of your future interests, the dermatology rotation offers
a fun, relaxed week for all students who are keen to learn.
193
Psychiatr y
Written by Aaron Gropper and Andy Chen, MD 2013
Edited by Julie Man and Lawrence Haiducu, MD 2014

Psychiatry is a 6 week rotation at one of 6 Greater Vancouver hospital sites (or
Kamloops/Kelowna), during which both inpatient and outpatient care is integrated. Students will
experience aspects of both adult and child psychiatry in a variety of settings including patient
wards, clinics, and the emergency department. Various common and uncommon psychiatric
conditions will be encountered, including mood, anxiety, psychotic, and personality disorders.
Students will vastly improve their pharmacology knowledge to become adept at psychiatric
medication use, as well as understanding patient management using the biopsychosocial model
of care.
Although some may regard psychiatry as a soft specialty of medicine, consisting of all talk and
little actual medicine, this is far from the truth. Psychiatrists train for 5 years of residency in order
to fully understand the depth and breadth of psychiatric conditions, to become experts in the
subtle nuances of each medication in a given drug class, and most importantly, to hone their
interview skills to the point where they can truly understand the psychiatric patient. Students
should enter this rotation with a respect for these skills, as it will increase enjoyment and learning
throughout their 6 weeks. Surgery may be a dissection of the body, but psychiatry is a dissection
of the mind!
Memorable Moments
Being on call in psychiatry can be among the most interesting experiences of
your third year. I can recall interviewing patients with wild psychoses, mania
and schizophrenia. But be careful and make sure not to believe everything
you hear like I did as a naive medical student. One night, a young man
presented to emerg complaining of suicidal ideation. He was well dressed
with a fashionable snowboard jacket and hair that was messy but just the
right amount of messy and held tightly by hair product. He stated that he had
been up for the past week binging on cocaine and if he were to leave the ED
he would likely OD and kill himself. He needed to break the cycle and stay in
emerg. I felt bad for the man and tried to convince my attending to admit
him, which she eventually did. However, I saw the man on two different
occasions when passing through the psych admitting ward. What I found out
later was that he was a regular, often looking for a place to sleep and a meal.
Although it takes a certain amount of desperation to check yourself into the
psych department for room and board, remember to not believe everything
you hear.
194
Life Outside of
Medicine
More than any other rotation,
psychiatry proves that there is life
outside of medicine. I am an avid
tennis played and as luck would
have it, so was my preceptor.
Once he found out about my love
of the game, he made a point of
finding time for us to play at least
once a week. While everyone else
was dogging it on the wards, I was
enjoying an hour of pure
relaxation!

The schedule depends on the placement location both in terms of which hospital and what
service the student is on. Certain services, such as PAU (Psychiatric Assessment Unit) or psych
emergency, have more regular hours; other assigned attendings may be part of the consultation
liaison team, and thus the hours (and workload) may vary from day to day. Typically, the average
placement should expect to start at work at 9am and end around 5pm. Depending on the
preceptor, students may leave early or stay until 7pm. In a given day, students may observe
interviews with the doctor, or actually see patients and manage the ward patients relatively
independently. Students typically will interview new patients, round on admitted patients, attend
family and interdisciplinary meetings, complete dictations, and participate in teaching sessions.

Call hours vary between hospital sites but are generally 5pm-11pm on weekdays and start 8-9am
and end at 6 or 11pm on weekends. Pediatric call is on weekends between 8:30am and 11am.
The number of call shifts depends on ones placement and can range from no call to 7 call shifts.
Depending on the site, there may be the option of being off-site as long as students are within a
reasonable distance to return for patient assessments and, if the call shift is quiet, the resident
may be happy to let students go early. Generally, call shifts involve assessing new patient consults
referred through emergency to triage the urgency of management required. There may also be
ward calls for inpatient management, but generally the psychiatry nurses are very competent at
managing common issues as appropriate orders would have already been provided through the
initial admission and daily rounds.

Students will not need to bring much, and this is one rotation where one won't need a
stethoscope. Bring along some notepaper, a clinical handbook such as Current Clinical
Strategies: Psychiatry, and a drug reference such as Tarascon Pocket Pharmacopoeia or Rx Files
for looking up psychiatric medications. Most importantly, dont forget a pen (or two or three)!

Each student will be assigned to see a preceptors patients on the ward and can expect to manage
4-8 patients at a time. The best way to keep track of patients is to maintain a personal day sheet
to record any changes in symptoms, medications, patient concerns and management plan for
each day. Depending on the preceptor, one may also do consults and therefore should document
the same items in ones own day sheet. Because histories can be very extensive, take notes on a
separate piece of paper and dont rely strictly on memory!
195

First Aid is a very popular resource to cover the basic knowledge and info. Toronto Notes, NMS
and Blueprints are also popular depending on the level of detail one requires. In order to prepare
for the exam, do questions - lots of them! Both Lange and Pretest are excellent choices for
practice. Reading the actual DSM is not recommended as an effective method of studying, as it
is too detailed and dense for practical student use. Instead, use it to look up specific criteria for
diagnosis, or when there is confusion after reading review books. One should also ensure that
one has learned, in detail, at least 2-3 commonly used medications in each psychiatric drug class.

ROTATION
Read around patient encounters in order to develop a strong understanding of their diagnosis,
issues related to it, and appropriate management. Recalling patients as case examples will help
when asked about a psychiatric condition in the future. Students should devote time each day to
reading about specific psychiatric disorders or drug classes. Ideally, by the time exams come
around, students will have a familiarity with the general picture of a patient with psychiatric
condition x, the main diagnostic criteria, and the initial and long-term management. Another
large component of learning in psychiatry is discussions with attendings and residents. Observe
their interview methods and questions, and use every chance available to ask questions and talk
about what the patient may have, and what to do about it.

Psychiatrists usually ask about basic DSM criteria for major diagnostic groups such as mood
disorders, psychosis, and personality disorders, and will often have students give their differential
diagnosis using the multi-axial diagnostic format. Drug classes, their side effects, monitoring
parameters and dosing options can also be quizzed. Students should also know how to inquire
about specific symptoms, and which are most important for a given illness. Overall, psychiatry is
a relatively relaxed atmosphere, and the doctors dont tend to grill students intensely (phew!),
though students should still be prepared to answer questions.

The only major (and required) procedure to observe and assist with in this rotation is
electroconvulsive therapy (ECT). Do utilize the opportunity to learn about ECT, its benefits and
risks, and its methods, as it is an unique chance to see one of the most effective treatments
available to psychiatry. There still remains a lot of stigma around ECT; during the rotation or
even in future practice, this topic may arise again from patients or opponents to the procedure.
196

Students should have no difficulty seeing the most common psychiatric disorders such as
depression, anxiety and schizophrenia. There should also be ample opportunity to observe other
mood disorders (e.g. bipolar), psychoses (e.g. schizoaffective), and neurological function deficits
(e.g. dementia and delirium) at least once or twice. However, there may be a smaller chance of
observing conditions such as personality disorders, sleep disorders or drug overdoses, as these are
more commonly managed in the outpatient setting.

There are many options in terms of exam preparation, and each has its merits, whether students
prefer to read review books throughout the rotation, to learn around their patients and
supplement missing information, or to do nothing but practice questions until they are adept at
recognizing psychiatric disorders based on the patient description.
The most likely pitfall of students in psychiatry is neglecting the exams altogether because they
expect them to be easy. Although this NBME may be the easiest of the 5 due to the nature of the
specialty and the more focused breadth of knowledge, students should not expect to wing the
exam and cruise through. Psychiatry requires a strong grasp of pharmacologic treatment
options, including benefits, risks, and side effects of medications. There are also subtle nuances
of diagnosis that differentiate between disorders. Do NOT leave studying to the last minute!
A steady pace of reading throughout the rotation will allow for a more relaxed and fun
experience, and prevent exam anxiety during the last week. Mentally review patients
encountered throughout the weeks to use as case examples of management, and the days prior to
the exams, repeatedly review the classes of psychiatric medications until at least 1-2 different
drugs per class are memorized, as well as how to use them appropriately in the treatment of
conditions.

The psychiatry exams consist of an NBME and a clinical reasoning exam (CRE), both occurring
on the last day of the rotation. There is no OSCE.
by a clinical question with (usually) 5 multiple choice selections. The questions are notably
longer reads than previously encountered MC questions from 1st and 2nd year medicine exams,
and have been known to contain extraneous or excessive details not required to answer the
question. As such, it is recommended that examinees first glimpse what the question is asking,
then read quickly through the vignette before providing ones best answer and moving on to the
next question. Time can be lacking if every question is read meticulously and overanalyzed!
197
The CRE is a 3 hour written exam consisting of 6 separate case-based questions, with two of
them based on videos of patient interviews watched during the exam period. One of the video
questions will ask the student to write a full mental status exam based on the interview, and the
other is related to a diagnosis and management plan of the interviewed patient. One of the
remaining 4 questions will be related to child psychiatry, and the rest of the exam questions will
either ask for:
1. A multi-axial differential diagnosis of the patient case, identifying the leading diagnosis and
justifying ones choices. Students should be able to identify diagnostic criteria that point towards
one disorder over another in their justification, the various social-environmental factors that pose
a problem with patient management, and also what the GAF score they assign the patient means
in relation to patient management (e.g. certification required?)
2. A complete biopsychosocial management plan for the patient case, with short and long-term
treatment options and expectations. Dont forget to consider factors such as patient safety (e.g.
need for hospitalization or certification) and obtaining collateral info (e.g. from past records,
family, friends, and case managers).
See the psychiatry section of the documentation chapter (p. 45), for explanations of how to write
a MSE, multi-axial diagnosis, and biopsychosocial management plan.
198
To find out where to go on the first day, CHECK YOUR EMAIL for a message from the department. Listed is
where students have met on day one in the past.
Site
Here is where
Where can I
students have met store my
on day one in the belongings?
past:
What kind of
teaching or
academic sessions
are there at this
site?
Is this a good site

for someone
interested in this
specialty?
What are common

problems patients
at this site have?
What is the call

schedule like?
VGH Students will be

emailed about
regarding meeting
location and time.
Storage depends
on the psychiatric
unit or location
you are assigned
to.
Resident teaching is
from 3-4pm on
Fridays. There are
also child psychiatry
lectures Wednesday
mornings at BCCH.
This is a good option for

any student interested in
psychiatry, as they will
see many common
disorders.
This depends on
which unit you are
assigned to, as certain
settings may encounter
more psychosis
patients, whereas the
short-stay assignments
may see more
depression and anxiety
cases.
There are
approximately 7 call
shifts during the
rotation, with 2
weekend call shifts
(8:30 am to 11 pm).
Normal weekday call
shifts span from 511pm.
SPH Students will meet

the site coordinator
on the first day in the
psychiatry building
for orientation.
Storage depends
on which ward
you are assigned
to, but typically
are put at the
nursing station
on the ward.
The chief psychiatry

resident will provide
teaching. There are
also child psychiatry
lectures Wednesday
mornings at BCCH.
This site is a great option

for students interested in
psychiatry, especially if
they wish to see a greater
proportion of psychosis
and substance-induced
disorders.
Psychosis is the most

common condition
patients have at this
site, and thus students
should become well
versed in the
evaluation and
management of this
group of disorders.
The call rotated

through MSIs
assigned to different
locations, with the
option to trade with
peers. Weeknights go
until 11pm or
midnight. Weekends
are from 8am-11pm
but often can be done
from home if students
are not too far away.
Site
Here is where
Where can I
students have met store my
on day one in the belongings?
past:
What kind of
teaching or
academic sessions
are there at this
site?
Is this a good site

for someone
interested in this
specialty?
What are common

problems patients
at this site have?
What is the call

schedule like?
Depression,
schizophrenia/psychos
is, bipolar disorder are
commonly
encountered among
inpatients and through
the psychiatry
emergency unit.
There are 3 call shifts

total, with
approximately one
weekday, one Friday
and one weekend
shift, but these are
relatively flexible and
can be switched
around if one asks the
chief resident. The
weekdays will be from
5-11pm only, while
weekends are 8am5pm, though you may
stay later as needed.
RCH The first day starts

with an orientation
session with the chief
resident in psychiatry
in the Sherbrooke
Centre (the main
psychiatry building).
Instructions will be
e-mailed regarding
meeting time and
location. The
resident will give
students a tour of
RCH, including the
underground tunnels
to get to the main
hospital building, the
resident/student
lounge, and
introduce them to the
wards before starting
the first day with the
attendings.
You can put your

lock on any open
locker in the call
rooms area, as
long as you let
Leila Bailey
(medical student
education
coordinator)
know which
locker youve put
your lock on
There are weekly

chief resident
teaching sessions on
Wednesday
mornings for 1-2
hours. Various lunch
hours throughout the
week, there are also
grand rounds, case
rounds, resident
STACER
interviewing practice
sessions, and
Jeopardy review
rounds! Child
psychiatry lectures
are videoconferenced
from BCCH every
Wednesday morning.
This is a nice option for

any student, whether
they are interested in
psychiatry or not, as
there is a good balance
of disorders that present
to RCH, and the psych
emergency unit is also
quite busy. If a student
is more interested in
outpatient or child
psychiatry, however,
RCH doesnt offer as
much experience in these
aspects.
LGH You will receive an

RGH email prior to your
SMH rotation informing
you where to go on
your first day.
A locker will be
assigned to you.
Most academics are

covered in the first
week. Childrens
psychiatry teaching
occurs once a week.
Smaller patient variety

but increased interaction
with your preceptor.

5 categories of psychiatric
disorders
5 classes of medications/treatments
1. mood disorders:
depression - MDE, dysthymia
bipolar - type 1 (manic) and 2 (hypomanic)
1. anti-depressants:
SSRI - fluoxetine, paroxetine, fluvoxamine
SNRI - (des)venlafaxine, duloxetine
NDRI - buproprion
SARI - trazodone
TCA - ami/nor- triptyline, clomi/imi- pramine
2. psychotic disorders:
brief psychotic episode (<1 month)
schizophreniform (<6 months)
schizophrenia (>6 months)
schizoaffective (at least 2 weeks of
psychosis without affective component
delusional disorder
2. anti-psychotics:
typical - haloperidol, loxapine, thioridazine
atypical - clozapine, olanzapine, quetiapine,
risperidone, paliperidone, aripiprazole
3. anxiety disorders:
generalized anxiety disorder (GAD)
social anxiety +/- agoraphobia
specific phobia - animal, environment,
blood-injection injury, other
obsessive-compulsive disorder (OCD)
post-traumatic stress disorder (PTSD)
3. anxiolytics and sedatives:

benzodiazepines - lorazepam, diazepam,
clonazepam (good for GAD)
anti-psychotics - haloperidol
trazodone
4. personality disorders:
cluster A: paranoid, schizoid, schizotypal
cluster B: anti-social, borderline, histrionic,
narcissistic
cluster C: avoidant, dependent, obsessivecompulsive personality disorder (OCPD)
4. mood stabilizers:
lithium - monitor levels (0.6 - 1.2 OK), renal
function, and toxicity symptoms
divalproex/valproic acid - monitor levels
atypical anti-psychotics - risperidone,
olanzapine, quetiapine
lamotrigine and carbamazepine
4. substance use disorders:

tolerance vs dependence vs addiction
5. therapy modalities:
electroconvulsive therapy
cognitive behaviour therapy
interpersonal therapy
psychoanalysis
exposure and confrontation therapy
201

Psychiatry is a rotation where most students may have no idea what to expect. However, many
students complete it with newfound appreciation for the skills and experience possessed by
psychiatrists that are necessary to fully engage and understand their patients. There are many
commonplace disorders and conditions (e.g. depression) that can act as comorbidities for patients
in all specialties, as well as a few unique disorders that medical students will only have the
opportunity to see during this rotation.
Students who start their psychiatry rotation with an open mind and a keen motivation to learn all
they can about this specialty will learn far more, and will garner the appreciation of their
psychiatry attendings and residents. Students who continue to regard psychiatry as a pointless or
menial part of their clinical training may survive the 6 weeks and pass the exam, but they will
likely be less satisfied than their enthusiastic colleagues.
By the end of the rotation, students will ideally have vastly improved their interviewing and
communication skills, and have seen at least a few patients or diagnoses that are unlike anything
previously encountered. Regardless of the disorder, every patient in psychiatry has a life story,
the details of which are pieces of the puzzle that one must complete to find a correct diagnosis.
202
Third Year Elective

During third year, you will have a 2 week elective during which you can do pretty much anything
you want. There are good instructions for applying for your elective on Medicol, so this section
will focus on some of your options and a few tips for making the most of the two weeks.
The third year elective is the only time during medical school where you get a chance to do
whatever you like without having to go through an accredited university to apply for an official
elective. You must have a physician preceptor who has agreed to oversee your performance and
write an evaluation at the end, but aside from that condition, you can choose whatever you
would like to do as long as it relates to medicine.
Some people do opt to do a clinical elective in order to try out a specialty they havent
experienced yet, or to visit a program they might be interested in applying to. While students are
discouraged from using their third year elective as a CaRMS specialty audition period, a
clinical elective might be a good option if youre thinking about a specialty that you wont rotate
through during third year (e.g. radiology, pathology, physiatry, etc.) or if you want to do a
competitive specialty and wish to visit a program to maximize your chances of matching to the
specialty (e.g. plastic surgery, ophthalmology, dermatology etc.). You may have better luck
organizing an out-of-province clinical elective, since at UBC, the fourth year students get priority
for clinical electives, so the specialty you want might not be available.
If you dont fit into the categories mentioned above, use your elective to do something fun and
interesting that you wont be able to do as an elective in fourth year. You could go international
and do some volunteering that isnt through a specific university program, attend a yoga retreat,
do some training in cognitive-behavioral therapy, finish up a research project, learn sign language,
or do outreach work in the downtown east side. The sky is the limit, as long as you can relate
what youre doing to medicine and you have a physician to oversee you. Try to think outside the
box and take advantage of this opportunity.
Set up your elective as early as possible to allow for any complications or changes, and send in
your application early (its due at least 4 weeks before your elective starts) to make sure you have
time to come up with an alternative in case your elective isnt approved. You will also have to
write a short essay reflecting on your experiences during your elective, so you might want to keep
a journal over the two weeks to have notes to jog your memory.
Make use of this opportunity to have some fun with medicine, especially since third year has its
share of exhausting and frustrating moments!
203
Memorable Moments
Elective Anatomical Pathology
My interest in anatomical pathology (particularly forensic pathology and
autopsy) lead me to do my 2 week elective in pathology to make sure that I
enjoy the day-to-day activities before I commit to it as a career. I opted to go
out of province to a city where the crime rate was such that I was pretty
much guaranteed a homicide autopsy while I was there. I was not
disappointed!
On the last day of my rotation, a murder victim was brought in. The police
were in attendance, as they are with any forensic autopsy, and since I had had
time to earn the trust of the pathologist, I was allowed to assist. I measured
external wounds, drew up fluids for toxicology, and recorded organ weights.
As we proceeded, we realized we would need the murder weapon in order to
compare the injuries we found with what allegedly caused them. A police
officer was sent to pick the weapon up from the police station, and much to
my delight, the pathologist suggested I go with him!
I climbed into the police van and we headed off. Once we arrived at the
police station, I got to go in with the officer and into the evidence locker. We
found what we were looking for the murder weapon, in an oversized
Ziploc-style bag and headed back to the hospital. I strutted through the
halls in my scrubs, flanked by a police officer carrying an evidence bag, and I
was practically glowing with excitement. I felt like I was on CSI!
No other experience in medical school has energized me quite like that day.
I had found my specialty!
204
Life Outside of
Medicine
Your third year elective can be a
time to experience a different
specialty or focus on studying for
a difficult upcoming rotation.
However, it can also be a time to
recover by choosing a light
workload and making rest and
relaxation your priority. Dont feel
guilty about doing so. As long as
you are learning something
during your elective, you are
successful. If you can come back
from your elective recharged, even
better.
YEAR FOUR:
ELECTIVES & CARMS
Compiled by Clara Westwell-Roper (MD/PhD Program)
Over view...................................................................... 206

Electives....................................................................... 208
Reference Letters........................................................... 212
CaRMS Applications...................................................... 214
CaRMS Inter views......................................................... 215
205
The CLERKSHIP GUIDE | Year Four: Electives & CaRMS
Over view
WORK-LIFE BALANCE
While there is much to learn and to organize in fourth year including travel, electives, and
CaRMS the workload is less intense than in Year 3. Call is less demanding and studying
becomes more focused, so you should have more time for friends, family, and other interests.
Some students intentionally choose electives that are light on call, and in general find it easier to
maintain a healthy work-life balance than in previous years. Many rotations are less demanding
and much of your time will be spent reviewing and adding on to previously learnt material. This
is a good year to make extra time for friends and loved ones, especially if you are travelling and
frequently away from home for electives.
BENEFITS
Benefits of fourth year include being able to tailor your learning to topics of clinical importance
without constantly focusing on exams, having more time to spend with friends and family, having
more autonomy and choice in clinical electives, and working fewer call shifts. You also have the
opportunity to travel to new cities, spend time in out-of-province hospitals to experience how they
run, and choose electives based on your interests and career goals. Following CaRMS matches,
you can enjoy your electives without the stress and uncertainty that comes with the application
process.
CHALLENGES
Major challenges include a potential loss of connection with friends and colleagues, frequent
travel, and anxiety about CaRMS matches. Try to make time to meet with friends and
classmates, as this does not occur easily when everyone is doing different electives. The lead-up to
CaRMS is the most challenging period, followed by uncertainty prior to match day. Keep in mind
that the vast majority of people are happy with their match result, and that you really do have
more control over the process than you think! Do your best to stay focused on learning and
patient care; this is often a challenge when you are working on applications or awaiting interview
invites or match results. Also keep in mind that there is a two-day OSCE in mid January, two
weeks before CaRMS interviews. Most people pass, but you do need to prepare for this.
EXPENSES
These are highly variable. Many students spend ~$3000-5000 on travel and accommodation,
including electives and CaRMS. Keep in mind that if you are applying to a competitive specialty
at a specific site, it may be to your advantage to have done an elective there and to make contacts
at other schools.
206
You can save some money by staying with friends or family, taking the train or bus between
CaRMS interviews (e.g. train in Ontario and bus between Edmonton and Calgary), and booking
flights well ahead of time when prices are lower. Carpooling during the CaRMS tour can give
you a chance to meet new people and is more affordable than the bus, particularly in BC or
Ontario (just ensure you are with good friends because the people around you can affect how you
handle the stress!). Take advantage of WestJet seat sales and the BCMA Club MD website for hotel
deals. Find out who will be in the same city and try to share taxis, car rentals, or hotels.
HOW TO PREPARE
Study hard just as you have been doing throughout your academic years! Keeping your CV upto-date is helpful, as is keeping notes on meaningful activities or experiences to help as you write
your CaRMS applications. Do your best to develop excellent working relationships with your
classmates and with others on your team during Year 3 rotations. Keep in mind that you may use
general reference letters from third year for your CaRMS application, so if you have a positive
experience with a staff member, do not hesitate to ask for one. Try to maintain your interests
outside of medicine as well.
Explore specialties early to figure out what interests you, and reflect on what it is about certain
specialties that appeals to you (or not). In first and second year, shadow in areas you think might
interest you, seek out mentors who can answer your questions, and talk to residents about their
training experiences whenever you can. If you are trying to decide between very different
specialties, consider trying to do these rotations earlier in third year. Finally, remember that most
people figure out what they want to do, even if it is at the very last minute you dont always
need to have a plan before starting clerkship!
207
Electives
CHOOSING ELECTIVE SPECIALTIES
Choose electives that interest you and help you cover a broad base of medicine as you prepare for
residency. Major considerations include experiencing multiple programs, building skills to
improve on weaknesses, and gaining experience that will be useful for your specialty of interest.
Ask staff and residents in your specialty of interest lots of questions about electives and what
they would recommend.
General electives are well suited to a four-week time period, while more specialized electives are
often two weeks long, although this varies considerably. Students often choose to complete
multiple two-week electives in their specialty of interest in order to visit as many programs as
possible. Completing these prior to CaRMS deadlines will allow you to experience more variety
in different fields and different cities. However, other students prefer to schedule longer electives
pre-CaRMS to provide more continuity and develop stronger relationships with preceptors who
can provide reference letters. Indeed, some electives work better in four weeks, providing more
opportunity for follow-up and time to get to know the staff. Following CaRMS, choose rotations
that you will enjoy and that will compliment your residency choice.
IN- OR OUT-OF-PROVINCE?
Out-of-province electives allow you to get a sense of what it would be like to live in other cities.
Think of places you would consider ranking for CaRMS, and also consider areas in which you
have friends, family, or other contacts. Out-of-province electives also provide an opportunity to
learn about differences in health care and teaching across the country and to meet residents and
staff in your programs of interest. However, do not feel that you must do an out-of-province
elective some students choose to do as many as possible and others do none at all; many
students hoping to match in-province choose more in-province electives in their specialty of
interest.
Sign up for out-of-province electives early, ideally before Christmas, as it can be difficult to find
an elective you want if you are looking later in the year. Consider applying for in-province
electives as back-up in case your out-of-province electives do not work out.
208
PREPARATION AND STUDYING

Most students find they spend less time studying in fourth year, but preparation for electives is
still important. Good general resources include eMedicine, the little red/blue/green book, Year 3
clerkship notes, Toronto Notes, and BC Guidelines for Family Medicine. Blueprints and Recall
books from third year are also helpful. Consider preparing for an elective the weekend before
using a general resource, and then read around at least one case each day using a more detailed
resource such as Up-to-Date. Keep in mind that you will be expected to know how to approach
and manage X if you had a similar case the previous week.
Time for studying is often limited during the day, especially on surgical electives, so efficiency is
important. Some programs will suggest areas of focus if you ask ahead of time, and most
preceptors and residents are happy to suggest specific resources in their area. Surgical electives
are a good time to practice suturing on your own.
ACCOMMODATION FOR OUT-OF-TOWN ELECTIVES

You can save money by staying with friends or family whenever possible. Check the housing sites
specific for the school you are visiting and ask other students who have completed electives at the
site to which you are travelling. Administration at each site is often very helpful in recommending
places to stay. Consider hotels or rental apartments, depending on your preference and budget
often you may be able to share with other students. Preceptors may also have some ideas about
where other students have stayed in the past. Consider your proximity to the hospital site, grocery
stores, a kitchen, and gym or other workout options.
DETAILS ON SPECIFIC ELECTIVES FROM PREVIOUS STUDENTS

Family Medicine Victoria (2 weeks). Excellent elective with Dr. Chris Fraser. Exposure
to inner city medicine, addiction, and detox.
Family Medicine Vanderhoof (4 weeks). Amazing community of GPs that provide
primary care, emergency, surgical care, anaesthesia, oncology, obstetrics, palliative and long-term
care. A true rural and full service family medicine experience and some of the best care delivered
in BC.
Family Practice Mackenzie (4 weeks). Clinic/hospital/lab all in one location,
supportive community, excellent preceptors, and a mix of clinic/emergency/procedures. The
community is very active: cross-country ski with the docs and nurses and use the gym and pool at
the RecCentre close by (pass provided). An excellent experience if you are interested in rural
practice. Free accommodation and extra funding for doing an elective in Northern BC.
209
Family Medicine, Mater nity Langley (4 weeks). An excellent opportunity for handson care and for managing patients independently. The clinic staff are welcoming and treat you as
part of the team. The nurses in the maternity ward are happy to teach and include you in all
aspects of care. You can see women in the clinic, deliver their babies, and perform well baby
visits! A highly recommended learning opportunity if you are interested in Obs/Gyn, Family
Practice, or Pediatrics.
Family Medicine, Mater nity Duncan (4 weeks). Supervisors are great
teachers/mentors and provide students with opportunities to run the prenatal visits, perform
procedures, and participate in deliveries. Flexible call.
Hospitalist Kamloops (2 weeks). Royal Inland Hospital is a busy trauma center with
interesting and diverse pathology. The service admits almost everyone, and other services
(General IM, Surgery, etc.) largely play a consulting role. The doctors in Kamloops are
outstanding and keen to teach, including ER physicians, internists, and pediatricians. The
hospitalists, however, are the main reason this is such a great rotation they function like
internists in the hospital but have diverse and interesting clinics on their off-weeks (eating
disorders, obstetrics, etc.). Recommended for those interested in Family Practice or Internal
Medicine. No call.
General Surger y, Nanaimo (4 weeks). Fantastic elective with staff members who are keen
on student involvement and flexible with scheduling.
Pediatric General Surger y Alber ta Childrens Hospital (2 weeks). Supportive staff.
Great mix of outpatient clinic and OR time. Lots of exposure to staff as there are few residents;
an opportunity for multiple reference letters.
Thoracic Surger y Kelowna (4 weeks). Work with all four MDs and the NP on the
service. 4.5 days per week in the OR. Minimal call. Be prepared and eager to learn; always listen
during the OR as they have a lot of experience and many pearls to share.
General Inter nal Medicine Nelson (4 weeks). Amazing physician (Dr. Malpass). Staff
at Kelowna General Hospital are friendly and helpful. Pathology is varied. Long days (12h) but
no call or weekends. This is an opportunity to learn a lot in a very supportive environment.
Emergency Psychiatr y Vancouver, VGH (4 weeks). A great elective for anyone
thinking of going into psychiatry. Lots of independence and responsibility in addition to one-onone time with preceptors reviewing cases. No call is expected but consider doing at least one
weekend call shift (12 hours) with whomever you plan to ask for a reference letter. It is easy to sit
back and get overlooked if you don't make an effort to take on patients.
Emergency Toronto, Sunnybrook (2 weeks). Highly recommended. The attendings are
excellent teachers. Huge assortment of presentations with lots of trauma and procedures.
Significant hands-on time with few other learners.
210
Spor ts Medicine, Nor th Shore (Whistler) (4 weeks). This elective is in Whistler (which
is not clear when you sign up). The clinic is busy and not always supportive. It is more family
medicine than sports medicine-based. Not recommended.
Dermatology, Ottawa (2 weeks). Good teaching; residents are intense and focused. Lots of
observation with limited hands-on experience.
Ophthalmology Ottawa (2 weeks). Good elective despite the difficult application process.
Lots of early mornings. Be sure to go in for clinics on the weekend - ask the residents about this.
211
Reference Letters
HOW TO ASK FOR REFERENCE LETTERS
Dont be afraid to ask for a letter most preceptors expect that you will, and if you work hard
they are usually happy to write them. You can always choose not to use the letter, so err on the
side of asking for too many as it is often difficult to go back later. If offered, accept a letter
regardless of whether you intend to use it or not. You can ask for a general or specialty-specific
letter in any specialty, regardless of your area of interest.
Communicate clearly regarding your learning objectives and your intention to apply to your
specialty of interest. Most preceptors are very supportive. For electives close to the CaRMS
deadline, tell your preceptor early in the elective that you are hoping for a letter of reference, and
offer to provide an updated CV and paragraph about yourself. This will ensure that he/she is
attentive and sees you doing enough to be able to provide specific information. Ask for regular
feedback so that you understand what your preceptor knows about your skills and competencies.
Near the end of the elective, ask if he/she can provide a strong and competitive reference letter,
but provide an out by making it clear that you understand if they are not able to do so. Ask in
person, and then follow up by email with information documents from OSA and any other
resources they request. Follow up as soon as possible after a rotation to ensure that your letter is
not forgotten and send a thank-you once it has been received. Online submission is easiest.
You may find that four-week electives are easier for getting letters than two-week electives, but
both are feasible. People who have spent a month with you such as CTU Attendings or General
Surgery Attendings are excellent people to ask. Keep in mind that it can be easier to make good
connections with the staff outside of busy hospitals where you may have more hands-on
opportunities.
WHO TO ASK FOR REFERENCE LETTERS

Ask anyone with whom you work well and establish a good rapport. This includes preceptors
who are not necessarily in a specialty to which you intend to apply, although referees in your
specialty and program of interest are clearly excellent choices. Think about individuals from
specific sites/programs, as wells as those who might have worked closely with you in multiple
areas and therefore have a reasonably accurate all-round picture of you, particularly if you feel
that your time with that individual highlighted your strengths. Consider individuals who can
speak to a particular skill set required for the specialty, and think about whether they would be
well known to your program of interest.
212
Pick letters based on your connection to the staff member and your experience in the rotation
particularly if you felt that your strengths were highlighted when working with that particular
individual. Select the people that are excited for you to work in that field someone who will say
great things about you and who is also enthusiastic. Try to capitalize on long periods of time
spent with the same Attending for example, if you spend six weeks with a Psychiatry preceptor,
they are likely to know you well enough to write a meaningful letter.
213
CaRMS Applications
The most important advice is to start early, especially on the personal letters. If you start in
September (as soon as you get your token to log in) and work on your application for a couple of
hours each week, the process will be less stressful and you should not be too pressed for time.
Taking the full two months will help ensure the work is manageable.
CURRICULUM VITAE
A well-rounded CV is important allow it to accurately represent the breadth of interests and
activities in which you have participated. Take some time to think about major strengths that
might set you apart from others, and ensure these are highlighted in your CV. Include activities
that are important to you, both within medicine and in a non-academic context. Focus on
activities that demonstrate an interest in your specialty as well as on extra-curricular interests,
research, and volunteering. You will likely be asked about much of what you put on your CV
during your interviews. Ensure you edit your CV extensively.
PERSONAL STATEMENTS
Keep in mind that personal letters may require significant time for reflection and editing. You can
use the cover letter that you wrote for your referees as a good first draft. Helpful resources include
program-specific information from websites, your own CV, previous applications, CanMEDs
competencies, sample letters online and those provided by UBC, and discussions with advisors.
Make use of your family and friends as editors; have several people read them over to provide
advice.
PREPARATION DURING YEAR 3

Keep your CV up to date, including all your clinical rotations with the number of weeks. Write a
cover letter for your referees explaining why you are particularly suited to your specialty of
interest.
Finally, keep a list or journal focused on meaningful clinical experiences as you progress through
third year. Start thinking about clinical vignettes from your own experience that will be helpful
both for your letters and for interviews.
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CaRMS Inter views

PREPARING FOR CARMS INTERVIEWS
CaRMS interviews require preparation and practice. You will need to quickly recall anecdotes
and stories. Start by going through a selection of the available sample questions and make notes
on what you want to remember to say. Useful resources include the interview database on the
CFMS website, the OSA interview preparation session, the PMP student handout, the CFMS
CaRMS Residency Guide, and specific information on program websites.
Start thinking about answers to common questions, especially why you are most interested in and
well suited to the specialty to which you applied. Most students who attend the PMP practice
CaRMS interviews sessions find them very helpful. While it can be intimidating to sit in front of
your peers and answer questions, this provides an excellent learning opportunity and muchneeded practice. Dont be afraid to look silly during practice it is better in practice than at your
interview! Also practice with family and friends to ensure you have a chance to practice telling
stories, listen to your wording, and receive feedback on how you sound.
Take time for self-reflection know who you are and your strengths and weaknesses. Think over
clinical encounters that were difficult, challenging, or taught you something specific. Consider
developing some key stories based on meaningful clinical experiences that highlight a variety of
themes related to commonly asked questions (e.g. adversity, leadership, personal qualities). Also
think about how to outline
CanMEDS competencies with examples from your training. Remember that this process is easier
if you keep track of meaningful encounters throughout medical school.
QUESTIONS TO ASK DURING INTERVIEWS AND SOCIAL EVENTS

Always think about a few questions you could ask if given the opportunity. These might cover
topics such as training opportunities both locally and internationally, the extent to which
residents feel prepared for practice when they finish, and what residents or staff might change
about the program if they could. Keep the discussion pleasant and positive but ask about the
programs strengths and weaknesses. In short, use the opportunity to learn about the program
and to try to figure out whether it is a good fit for you. Ask about whatever genuinely interests
you.
215
If you already have all the information you need regarding the program, ask your interviewers
about the sites they are from, their practices, and their impressions of it. It is sometimes possible
to ask about the interviewers backgrounds at the beginning of the interview, which can help to
guide your answers. During social events, ask the residents whether they are happy (in the
absence of any faculty). Ask them about call, group dynamics, the city, and why they chose the
program vs. other programs and other sites. Ask them what they like best about the program,
about its best and worst attributes, and whether Attendings are keen to mentor and teach.
TRAVELLING FOR CARMS

Consider booking interviews with friends who are applying to the same specialty, allowing you to
book flights and hotels together. Take care of yourself during this time; bring some runners and
shorts in case your hotel has a gym, and remember that it is much colder in other parts of the
country, so dress accordingly. Consider a rolling or easy-to-carry garment bag, and try to stick to
carry-on luggage to save time and stress at the airport. Try to give yourself lots of time between
interviews, allowing for unforeseen winter travel delays. Some people try to squeeze interviews
together in order to take a vacation at the end, but leaving time to recharge between interviews
can help.
HOW TO DRESS
Pack your suit in a carry-on so that it is always with you, and try to travel light. Attire for
interviews is typically business formal suits are the standard. However, you can check the
CaRMS website for the program for and specific instructions regarding the interview, as some
rural programs may have other dress guidelines. You may need to bring your luggage with you to
an interview, and there is always a room in which you can store it. You may want to take notes
during the orientation/presentation sessions but do not need to bring anything into the interview.
Most invitations will tell you the dress code for social events. This is usually something close to
business casual, although some events may be considerably more casual. You might consider
bringing two options (one dressier and one more casual) if you are unsure about the venue.
216
THANKS FOR THE

READ!
And with that concludes this unofficial guide to clerkship. Hopefully its
been helpful to you in whatever way or form youve chosen to use it.
Thanks and acknowledgements should go to all the great writers and
editors of the guide, as well as the UBC Faculty of Medicine for supporting
this endeavour. It is our hopes that there will be continued revisions and
additions to this resource over the years, so that it may continue to provide
advice and guidance to the many 3rd years to come who are lost and
confused in the chaos that is clerkship.
Regardless of the difficulties, obstacles, trials, and tribulations that each of
us may encounter in our education and careers, never forget that medicine
is a continuous learning process, and that we should always seek to grow as
physicians, therapists, and advocates for our patients. Good luck to
everyone in your future specialties!
-The Clerkship Guide Team
217
The CLERKSHIP GUIDE | Thanks for the Read!

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The unofficial UBC Medical School sur vival

The CLERKSHIP GUIDE | Table of contents

The CLERKSHIP GUIDE | Contributors

Good luck, and hang in there!

The CLERKSHIP GUIDE | Welcome to 3rd Year!

A special note to the brilliant students studying outside VFMP: Although

The CLERKSHIP GUIDE | Welcome to 3rd Year!

How to choose and rank your track..................................... 5

The CLERKSHIP GUIDE | The Basics

How to choose and rank

BIG 3 FIRST: PROS

BIG 3 LAST: PROS

The CLERKSHIP GUIDE | The Basics

A FEW OTHER THINGS TO KEEP IN MIND

Return to: Table of Contents

The CLERKSHIP GUIDE | The Basics

Valuable pearls from 1st and 2nd

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The CLERKSHIP GUIDE | The Basics

Dont miss: What third years

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The CLERKSHIP GUIDE | The Basics

How to prepare for clerkship

WHAT TO DO ON DAY ONE OF YOUR ROTATION

WHAT TO BRING (AND HOW TO CARRY IT ALL)

The CLERKSHIP GUIDE | The Basics

Money and/or a credit/debit card

toothbrush & toothpaste

small hand towel

FOOD! And lots of it! (Dont forget something for breakfast!)

study materials to read if things are quiet

The CLERKSHIP GUIDE | The Basics

HOW CALL WORKS

HOW TO BE A PART OF YOUR TEAM

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The CLERKSHIP GUIDE | The Basics

Best clerkship smar tphone apps

The CLERKSHIP GUIDE | The Basics

How to study during clerkship

Return to: Table of Contents

The CLERKSHIP GUIDE | The Basics

Return to: Table of Contents

The CLERKSHIP GUIDE | The Basics

Impor tant pearls of advice from

Enjoy your time now!

Be good to your fellow med students- share information and commiserate.

Good luck. It will be a tough year.

The CLERKSHIP GUIDE | The Basics

Check your ego at the door. Assume nothing.

Be on time! (No 5 minute grace period!) Be keen!

Have a fun-filled summer after year 2!

You will be alright.

Return to: Table of Contents

The CLERKSHIP GUIDE | The Basics

5 things to take FULL

4. ACADEMIC HALF-DAYS AND SPECIALTY/GRAND ROUNDS!

The CLERKSHIP GUIDE | The Basics

5. ANY SPARE TIME!

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The CLERKSHIP GUIDE | The Basics

Ten moments that will happen in

1. YOU WILL FEEL STUPID.

The CLERKSHIP GUIDE | The Basics