How to Clerk Patients

[C&P]

I have been listening to the case presentation by medical students ever since I started working here. After many years of working with house officers, I admit the feeling was totally different. I think because of the intent of the presentation. One is for teaching purpose to pass an exam, while the other is for working purpose to manage patients.

So yes, I get confused initially on how to teach them. But after few days of “acclimatization”, I am writing this hoping that it can serve those two purposes simultaneously. I hope you will find it beneficial because the ultimate goal is still the same i.e. to be a safe doctor and to manage your patients well.

STEP 1: PRE-MORBID STATUS

“Assalamu’alaikum pakcik.”

The usual stuff. We all learn this in medical school. Greet your patient well, smile and most importantly, create a quick rapport and trust. Pakcik is about to reveal everything to you. He needs to trust you.

In the first few minute, you need to quickly get the pre-morbid status. Ask about underlying medical illness(es) and the follow up. Which clinic, which hospital, government or private? Also, explore previous history of admission(s) and why. And for house officers especially, list down all current medications correctly because you need to indent them on the medication chart later.

But most importantly, you really need to ascertain the PRE-MORBID FUNCTIONAL STATUS. How is the patient before this current illness sets in? Can he/she run a marathon or easily breathless going to the toilet? Is the patient as normal as you are now, or totally bedbound at home? Anyone taking care of him/her or he/she is totally independent?

You need to establish this because the aim of management for all patients when you clerk them is the same. YOU WANT TO TREAT THEM AND BRING THEM BACK TO THEIR PRE-MORBID CONDITION. Walking or running, on a wheelchair or on a trolley, our aim remains the same for all patients i.e. to discharge them well and bring them back to their original status, if not better.

Now, here’s the catch. You don’t have forever for STEP 1. It seems like a lot to ask, but you have less than 5 minutes to do it. Because if you read my previous post on HOW TO PRESENT CASES (link below), you will know that the next step is the most important step of all. Finish your STEP 1 quickly, or skip it if you know you are wasting your time. You can come back to it later. Because here comes the most important step.

STEP 2: REASON FOR ADMISSION

The first thing you have to do is to find out whether it is an ELECTIVE or an EMERGENCY admission. Let’s look at them both separately.

ELECTIVE means patient comes for a specific reason. Someone asks them to be admitted. It can be either for surgery, for procedure, for medication, or simply, a generous favour from that “someone” (read: your boss).

It is not that difficult to clerk an elective admission. They usually come to you with a diagnosis and you just have to go retrospectively and figure out the story leading to that REASON FOR ADMISSION.

For house officers, you can dig through the previous records but for medical students, you just have to ask the history. The problem is, when your patients do not bring anything with them and say, “Entah, doktor suruh masuk hari ni, saya pun tak tahu untuk apa.” Then, you are screwed! 😁

But, trust me, there is always a way to figure that out. Di mana ada kemahuan, di situ ada jalan. Seek for the answer, and you will find it. If, you are willing to find it.

EMERGENCY, on the other hand, comes without a diagnosis. It is your job now to make up the diagnosis. This is where your medical school training comes in handy. Chief complaint, history of presenting illness, systemic review, general physical examination, focused physical examination and finally, PROVISIONAL & DIFFERENTIAL DIAGNOSIS.

A good clerking is when after 5 minutes of history taking, your mind has started listing down the PROVISIONAL & DIFFERENTIAL DIAGNOSIS. Way before you even touch the patient! This is a good clerking. You need to do a lot, I mean a lot, of clerking to achieve this. Clerking one patient per week is definitely not enough!

In the clinical years of medical school, your patients are your text book. That’s why, as a medical student, my lecturers scolded us if we didn’t clerk at least 2 patients per day. That’s why, as a medical student, my lecturers screamed at us if they see us bringing books into the ward. “If you want to read, go to the library, don’t come to the ward”, they said.

A bad clerking is when after 15 minutes of history taking, you still have not reach the diagnosis part. When you start to sweat and looking at your watch non-stop during long case examination, you know that you did not do enough during those clinical years.

STEP 3: OUTLINE YOUR MANAGEMENT

This step needs practice and experience. INVESTIGATION and TREATMENT. The more you see, the more you know.

This is where, your books will not help you much. To a certain extent, yes, but most of the time, not. This is where, the amount of time you spent in the ward, matters.

This is where, for medical students, the house officers and medical officers are your good friends. They are the go-to persons who have the explanation for every investigation and management plan.

This is where, you will see how a clinical decision making differs, from one doctor to another, and from one hospital to another. But no matter how different they are, there will always be an explanation and most importantly, the principles remain the same.

You have to know those principles. But remember, you can never reach STEP 3 if you have trouble finishing STEP 2. For medical students, trust me, the moment you finish STEP 2, you have passed your examination. If much of the question or discussion lingers at STEP 3, a pat on your back because you are a distinction candidate.

And I can assure you, if you perform well as a medical student, if you can do STEP 3 as a medical student, trust me, your housemanship will not be as bad as what is being portrayed publicly nowadays in the news. Because this is also the difference between a good and a mediocre house officer. The good ones can complete STEP 3 on their own, while the other waits for the medical officers to do it.

Which medical student are you?
Which house officer are you?

STEP 4: DISCHARGE PLAN

The biggest clerking mistake, to me, is when you clerk only for a certain period of time.

For house officers, you clerk a new admission and outline your management only up until your working shift is over. Right? Because by then, you will do passover and bye-bye, not your problem anymore. When you do a review, you only know about what happened yesterday and the next 24 hours, or up until your shift is over as well. Right?

Because if you ever work with me, you will know my favourite question to you will be, “when can patient be discharged?” It does not matter whether patient is still intubated or smiling at you. When can patient be discharged?

Similarly, medical students will clerk a patient only up until the bedside teaching is over. Right? Then, you will do the same bye-bye and if you stay around, that means the patient is your subject for case write-up. Right?

I was once a medical student as well. I know. 😅

Train yourself, the moment you start STEP 1, you have started thinking about STEP 4. Remember the thing I said in STEP 1 about “treating them and bringing them back to their pre-morbid status”? A good doctor does that. A good doctor TREATS THE PATIENT, NOT THE DISEASE.

The moment patient is admitted to the ward, you should anticipate everything up until the discharge plan. This is the difference between an elective admission who is discharged in the morning and an elective admission who waits until late afternoon, sometimes night, for a discharge summary. This is the difference between an emergency admission that does well and an emergency admission that does not do that well.

I know, it is easier said than done. But after reading this, I hope you have a rough idea about clerking a patient. I know I only scratch on the surface because managing a patient is not as simple as listing down the steps. You need a lot of practice, plenty of guidance and a hint of scolding in between. We all learn from mistakes, provided that we want to learn from them.

I leave you with this quote, “Medicine is science, but practising it, is an art”. Hence, you need to learn the art of clerking a patient. Similar to learning the art of presenting a case and making a referral.

There are no shortcut to it. We all learn the hard way.

Credit to: FB Aimir Ma’rof (click on the link below)

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