Getting the Most Out of Your 2018 Clerkships

Remember back when you were a student in podiatric medical college? Remember as your third year came to a close and you began your fourth year externships (now called clerkships)? It was a somewhat nerve-wracking time, what with having to travel around the country, visiting residency programs that you really didn’t have much of a clue about. Was this program going to be my future residency? Is the housing going to be legitimate? How am I going to afford the travel expenses? These questions, among others, really haven’t changed over the years. But there have been some improvements in the process. For example, the rotation calendar for fourth-year podiatry students has become standardized across the country. This makes the process easier for both students and residency programs. Additionally, more information about the programs are available now than when I was a student (but we can definitely increase this information further). A good number of my Western University students are asking for advice on preparing for their clerkships. A few of the schools start clerkships during the students’ third year, beginning in April. Although a bit early in their training, this time-advanced schedule allows students to have a greater number of clerkships before the all-important residency interviews. Given the importance of finding, choosing, and matching with a residency program, one can easily understand the motivation students have in getting this right. Over time, I’ve listened to feedback from my students who’ve experienced clerkships and, coupled with my experience with residents, have a reasonably sound understanding of what is needed to succeed. With that in mind, here are my top eight pieces of advice for students about to start clerkships. Let’s split them into what “to know” and what “to do.”

My Top 8 Tips for Succeeding in Clerkships

What to Know

Know the fundamentals - You should know your basic podiatry, including the concepts and skills you’ve been taught during school. All programs will expect you to know the basics (at the very least). For example, you should be able to diagnose most complaints and determine a treatment plan. You should have a grasp on the biomechanics of most lower extremity issues. You should be able to clearly present a patient to your attending and get to the point quickly. If you’re weak on something, start reading about it now.
Know that the clerkship is really a one-month interview - We’d love it if clerkships were pure learning opportunities, but let’s join the real world. Working with someone for a month affords programs an excellent chance to learn who a student really is and if that person will be a good future resident. With this in mind, don’t do anything stupid during the clerkship like getting drunk or having a questionable sexual encounter with someone at the program. Make your online social media accounts private. You don’t want some compromising image to make it to a program director’s desk. Don't be rude to anyone, including the support staff. On the contrary, be open to learn from everyone, be helpful, kind, and generous. Be the first one there and the last one to leave every day.
Put yourself in the programs’ place - If you were a resident or an attending at a program, what kind of future resident would you want? Think through these characteristics and, if you want that program, mimic or demonstrate those characteristics. It’s pretty obvious they don’t want a lazy person that doesn’t want to work hard. It may be less obvious to determine if they want someone with heavy research knowledge and experience. I like my residents to be decisive, independent thinkers, and able to challenge me intellectually. Other program directors will want something different. This is hard to figure out, but most important to clarify.
Research the programs - Knowledge is most definitely power in this case. You must know what you’re walking into when you attend a new clerkship. Who are the attendings? Have they written papers? If so, read them – all of them. Read about the hospital or the clinic. Speak to the residents via phone or email if possible. Ask specific questions to get specific answers. If I ask, “How busy is your program surgically” you’ll get a vague answer like, “We’re really busy.” If instead I ask, “How many rearfoot cases have your second years done over the last six months”, I’m more likely to receive a specific answer.

What to Do

Practice suturing and hand-ties - This is the one physical surgical skill that a residency can use to see both how hard you’ve been working (ie how much you’ve been practicing) and predict how easy it will be to train you surgically. In my opinion, this is only useful for the former. I know of no proof that suturing skills correlate with or predict future success as a surgeon. Students should be aware of one fact, though. When they get a chance to suture, it will be at the end of a procedure in most cases, which means the team is in a hurry to get out of the room. This will translate to a certain impatience while you’re suturing. Here are a few tips to help: (1) Practice a lot. (2) Leave a slightly longer tail during the first throw of a knot. Your tendency will be to pull the suture out, and leaving it a little long will decrease this risk. (3) If your hands shake from nerves, place your elbows against your sides. It’ll decrease the shaking. (4) If you are in a bad position to suture (you should be facing the incision with a clear field), ask to move. Don’t be shy about it. If the table is too high or low, ask in a clear voice to adjust the height. “Table up, please.”
Communicate why - This could also be titled communicate the details. If knowing the fundamentals is important, being able to communicate “why” makes you more impressive. For example, if you present a patient with plantar fasciitis to me, I might ask, Why does the patient have that diagnosis? This would require two answers. First, I’d want to hear your history and physical reasons to support the diagnosis (this is what everyone should be able to do). Second, and more impressive, is understanding the biomechanical reason for plantar fasciitis. If you tell me “pes planus”, I won’t be impressed. If, instead, you explain about the patient’s flexible forefoot valgus causing subtalar pronation and increased pull from the gastrocnemius-soleus complex contributing to increased plantar pressures, all leading to degeneration of the fascia, I’ll know you’re further along and are thinking. Remember, the paradigm of modern medicine is determining a diagnosis, understanding what is occurring physiologically, and then treating that cause. If you can’t do this as a podiatrist, you won’t be successful.
Interview the program - This one isn’t literal. You’re not going to actually interview the program, but you should evaluate the program as you go to find out if it’s what you want and if you’ll be a good fit. For example, some programs are very academic while others are not. As you proceed through the clerkship, you will learn just how academic they are. You will also need to know if that’s what you want. Do you want something structured that pushes you to read and study certain things or do you want a more free-form program? This one is highly subjective, although all programs are required by the CPME to do a minimum amount of academics. You might want a heavy surgical program or one with both surgery and clinic. Be conscious of what the program has to offer while you’re a clerk to see if it would be best for you.
Be appropriately aggressive - I’ve said this before in other editorials, and I’ll repeat it here because it’s so important. Most residencies don’t want someone who is a shrinking violet, afraid to move away from the wall or offer an answer to a question. On the other hand, more programs also don’t want an overly aggressive jerk that pushes in where they aren’t welcome and works outside of the normal student and social boundaries. Being appropriately aggressive requires a balance of a variety of social skills that some people simply have a very hard time finding. Be friendly when you first meet someone. Call all residents “doctor” until they give you leave to do otherwise. Don’t appear shy (even if you are). Ask for permission to do clinical activities, again, until you determine your parameters as a student. For example, while waiting for a surgery to start, ask, “Is it ok if I get the tourniquet ready and draw up local anesthetic?” Ask before the resident tells you what to do. Don’t just do the thing (at least at the beginning). You may find, for instance, that they’re doing a popliteal block and don’t need local anesthetic.

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My last piece of advice for clerks is to maximize the experience in every way possible. Read every night about what you’ve seen. Offer to take call with the residents (if it’s voluntary). Learn everything about the people with whom you’re working. Squeeze the educational learning out of every clerkship. If you do, you’ll find that the year will go by incredibly quickly, and you’ll be proud to look back on a very beneficial whirlwind year that has gotten you much better prepared to begin your residency.

Good luck and best wishes.
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Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
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