Two Paths Through Clerkship - YEGMDPod

Understanding Clerkship and Sam's ICC Choice Hey oscillators, it's Jess B and I'm here to help you get your MD. Welcome back to another episode of YAG MD Pod. Today we'll be revealing all the hidden secrets of life on the wards, which you will experience as a third and fourth year medical student at EU of A. We also have a guest with us today. It's my pleasure to introduce Sam, a student who just finished his fourth year of Med. Speaker 2 Thank you Jessica for the warm welcome. As Jessica shared, I'm a fourth year Med student and I was recently matched to Internal Medicine at the University of Calgary. It's a pleasure to be on the show. Speaker 1 So Sam and I both have a lot of experiences to share with our listeners about our clinical experiences. But first let's just dive into the essence of what clerkship actually is. So the way medical school works at EU of A is it's a four year program. The first two years are classroom based where it's kind of like your standard university experience where you get a lot of lectures and then you kind of learn the fundamentals of how to treat various conditions in various body systems. And then in your third and your fourth year, they unleash us on to the hospitals and then we get to interact with real patients and actually try to help them a little bit. There's also two different ways you can do your clerkship when you're in 3rd year. We're offered a choice at kind of halfway through our second year if we want to do what's called like the standard rotation based clerkship system, where every six or eight weeks we kind of get like a deep dive into a specific specialty at one specific hospital. And then after the eight week period, we move on to like a new specialty. So we might do like 8 weeks of Pediatrics, for example, 8 weeks of internal and then like six weeks of psychiatry. There's another style of clerkship which Sam actually completed called the Integrated Community Clerkship Stream, where instead of all of that complicatedness, he just spent a year out in rural Alberta and just kind of saw everything at once as it came in. So Sam, as somebody who chose the ICC stream, why? Speaker 2 Yeah. Just to kind of backtrack a little bit in terms of IC, and it says exactly as you say, it's a longitudinal program and there's no set blocks. So we don't get 8 weeks in surgery. We don't get six weeks in internal medicine or however it is in the urban community. We get about 10 months approximately in rural community. And we just learn as we go. There's still kind of set academic half days where you learn the fundamental information, but we see different cases as they come in through the door of the emerge or of the hospitals that we're working at at the time. And so there's a lot less structure to it, but you get the opportunity to learn the information at one point and then relearn that information again in a couple of weeks time, a couple months time again. And that helps to reinforce that information. And so you don't kind of learn all about your surgery and then kind of forget about it because you're not interested in surgery a couple months down the line. And so and so for me, my motivation for choosing ICC was really twofold. Firstly, having grown up in Calgary in large cities, I would say, and then working in Toronto, I've never really had the experience of rural medicine or living in a rural community for that matter. And so I thought ICC was a fantastic opportunity to learn about what rural medicine and what living in a rural community actually really looks like for me. And I think that also really helps build me up as a physician further down the line in terms of being able to serve rural communities. When I see patients in the hospital or on the wards and kind of understanding their social context, which is I think very different from individuals who live in an urban centre, especially in terms of their access to health resources. And the availability of these health resources are very different. And my second point of the reason I choose chose ICC is because of that actual lack of structure, I think was actually really something that attracted me. I would say that I'm a self-directed learner. I like to learn about things as they come in. I like to read around interesting topics to myself. And having that 10 months to actually learn and relearn that information was something that's really attractive to me. To me, I think it really makes me stronger candidate having to consider all these different topics at different points in time rather than kind of having the mall together at the same time in terms of a block system that that ability to reproach that information is really helpful. And also because of that lack of structure that is in ICC, there's a little bit of opportunity to do a bit of career exploration, which would not otherwise happen in an urban centre. So for example, in 3rd year, there's really no emergency opportunities in in the core rotations. Maybe through the electives, there will be a little bit of that. But in rural community, I'm able to do that because that's one of the places that we learned about acute medicine, acute care of surgery. So we get that exposure in emergency medicine. The other aspect of it is if I'm really interested, say anesthesia, I had the opportunity of kind of going early for the surgery cases and sticking with sticking together with the anesthesiologist and chatting with them and learning a little bit about anesthesia and helping to intubate. That flexibility I don't think really exists in the urban community. And so for me, that ability to be flexible in my learning and learn as much or as little as I want about a topic was really attractive. And also that ability to experience real medicine was also really attractive for me. Comparing Rural Healthcare and Urban Training Paths I mean I beg to differ in that first of all I got to intubate on my Gen. surge rotation in the city, albeit once but I did. There was 1 anesthetist who let me intubate. My follow up question I guess is like you said, you'd never been burned before. What did you learn? What did you learn about rural Alberta? Speaker 2 Yeah, Roberta is not as conservative as one might actually think. Obviously, there is different groups of people who are a little bit more conservative, but there is, I think overall, in terms of health, a lack of access. One of the examples that I really remember is the access to abortion care in central Alberta. It's something that's almost nonexistent, maybe partially because of the political climate in that area or just physicians and pharmacists not really willing to offer that kind of care. And so that lack of access means patients are traveling either to Edmonton or Calgary even to actually receive their abortion treatment and options. There is a group of physicians, which I will not name because of the political climate there, that are offering this virtually throughout all of Alberta, which is really impressive and really helpful to helping to bridge that lack of access. And I'm sure there's other areas of differences of access to healthcare that I've not directly witnessed or not really recalling immediately right now. That's really important to address. And so keeping that in the back of my mind as a future internist as saying that we have all this ability to do all these fancy things in the city, but that's not necessarily the case for rural Albertans. And so we have to be a little bit more creative at times in terms of how we manage these patients or trying to actually optimize their treatment when they do come to the city to do all the tests that needs to be done in the city so that we can provide optimal care for them. Speaker 1 Yeah, that's wow. You learned like a lot about like rural medicine in general just from doing a year of ICC. That's really impressive. I guess I can share a little bit about my experience now with the listeners. I chose not to do ICC. I chose to do the tracks based system. And for me it was more so because I just wanted kind of a general glimpse of like what each specialty is like. And well, I am someone that actually does want to practice rural. There's lots of opportunities in the regular tracks to go rural, like I'm in the regular track and a third of my rotation this year is going to be rural. You have the opportunity at EU of A in your family medicine block to do 8 weeks of your family medicine in a rural community. In Alberta, it's mandatory for everyone to do 4 weeks, but you can increase that to 8. And then this year for our obstetrics and gynecology rotation, they actually added in the option of a rural site, which I'm going to be one of the first groups to try out. So I am excited for the perspective of more hands on. I think the reason why I remained in the city is I feel like I just learned better that way. Like I'm not someone who like really knows how to integrate everything. And this might be a bit of like a character flaw, but I think that I am more of a specialist by nature and that I really like hone in on specific details. And that is just kind of how my brain works. And I like learning about like one topic in detail for a more detailed period of time. Also I'm not organized enough to like remain on top of the material. Like you threw me in rural Alberta for a year and said like oh you're exams four months from now I'd probably hit the ski hill every weekend and like not read every day. So in many ways like me doing the track based rotation was away for like me knowing myself to keep on top of my work. Also I feel like the experience is really sight dependent. Like I did want to do ICC for the perspective of being rural but for my career interests at the time and they would be in surgery. I heard that like not every site has the same exposure to the OR and that there were some sites that actually got like no or exposure time and they did their like surgery requirements for the course through consults in the emerge. And then those consults were like taken off to a different hospital like Sylvan Lake, for example. Like you guys traveled to Red Deer, a different community to do that. And I don't know if it was mandatory or not for you guys. Like if you guys didn't want to, could you just like not go and like still meet those requirements? Speaker 2 Yeah, I think that's a really good question in terms of the sites tendency of the exposures that you get. And I think that's the same for all rural communities, that there's different levels of expertise in each community. And yeah, like you alluded to, I was part of the Sylvan Lake crew and we do a lot of our cores in red gear. It's about 30 minute commute, basically the same thing as if you wanted to go from say some of the hospitals in the urban centre to a different hospital, I would say about a similar amount of commute. It's all highway though, so really quick and kind of goes by easily in that regards. And yes, we do our cores in red, yeah. So we did hospitalist medicine, internal medicine there. We did Pediatrics there, we did general surgery there and we followed the family physicians for the obstetrics training there. And so we did get a lot of exposure in terms of that diversity of, of, of, of the core rotations, I should say there. Um, and I think that's really good in that we are the only kind of learners there with the attendings and the staff physicians. Maybe there's a clinical assistant, maybe there's one resident on, but there's no more than that really. And so there's a lot of chances to have that exploration in that conversation with the attendees to learn directly from them and from their skill set. But kind of going back to that question about differences in expertise, I think that comes back to being an adult learner and being a learner that kind of understands what the limitations are of your community. Identifying that early on and then chatting and talking with the program director to see how or what ways there could be to kind of overcome those barriers. For example, the Silver Lake site, although we do have psychiatry in Red Deer, the teaching around there was not that great from previous cohorts. And so I brought this up to the program director at the time and we were able to come back to EU of H UAH to do some emergency, I guess days to kind of see some of those psychiatry Peach patients and get those kind of learning points in that regard. And so I think in terms of dedicated blocks and dedicated time for each block, there might be some whacking objectives that aren't being really met in clinic. But coming back to the requirements of actually graduating medical school, you don't actually need to step in an OR to actually graduate medical school. It's not part of the requirements. So you can meet those learning objectives either through didactically teaching or just through consoles, as you mentioned. But yes, if you did want, say, more surgical exposure, then that would be something that would be challenging to get. And that would be a conversation with the program director of ICC to kind of see how you get better exposure in that case. Speaker 1 So Sam, why did you choose Sylvan Lake specifically? And if you were like assigned to an ICC community that wasn't Sylvan Lake, would you still have done ICC? Speaker 2 So my primary reason for choosing Sylvan Lake is not because I was well read U on all the communities, it was because it was kind of close to Calgary, which is home for me, and kind of close to Edmonton, which is where all my friends were. And so it was the best of both worlds. If I wanted to go home and see my family and help them cook for me, that's opportunity to do so. If I wanted to come and hang out with my friends, that was also an opportunity to do so. So it was purely geographically and not so much the learning opportunities that were there. And to the second part of that question, what I've done ICC, if it was a different site, I would say yes. Speaker 1 Even if that site was high level. Speaker 2 High level is not one of the sites. High level is not one of the sites for. Speaker 1 ICC. We're assigned to it though. Speaker 2 I think. Speaker 1 I would Grand Prairie. Speaker 2 I would say that I had the opportunity of choosing Peace River. It was a great learning site. Colleagues who were at the site did a lot of really cool medical stuff, did a lot of interesting activities there as well as learning. And so I think it would have been a fantastic learning site. I might have been a little bit more homesick and but I think would still choose it for that learning opportunity and that ability to learn as an independent learner and having that one-on-one time with not only the staff, but taking care of the patients. And I think this goes back to another strength of ICC is that because there isn't as much, I would say, support in terms of residents and other colleagues, you are very much responsible for your patients, you and the staff. So there is someone to kind of as a safeguard for you, but you are entirely responsible. So at the start of ICC, I was rounding on my own patients already. It was scary doing so and kind of being pushed to make a management plan, being pushed to do investigations and being pushed to kind of come up with a differential around those investigations that's already been done. But I think having gotten comfortable with it early on really helped me grow once all of that kind of problems were out of the way and I was able to kind of learn that on pace moving forward. And I think Peace River being so far away from a coronary centre such as Edmonton makes that even more interesting and having to understand how to utilize the resources that you're given and that community will make it a lot more interesting of the learning opportunity. So, you know, even though I was in Sylvan Lake, if I was in even a more rural community, I think that would actually been more interesting for me. But the reason I chose Silver Lake over Ice River was simply because I was a little bit easily homesick at the time, and so I didn't want to go that far out. Speaker 1 Fair enough. I mean, I did go to Peace River for my P and me and 2nd year, we actually have another episode on that. It's already out actually. Inside the Daily Life of Medical Clerkship So I'm just going to direct our listeners to listen to that episode, but let's talk about like a day in the life or like a week in the life, like what actually happens out in Sylvan Lake. Speaker 2 There's not as many boats as I had thought. Unfortunately, I was not invited out on a boat during my IC time by any of the docs. I don't think actually any of the docs. Speaker 1 Actually, had I thought you were, I thought you like sent pictures of yourself like on a boat with members of my class like last year. Speaker 2 Members of your class were on the boat. I was not. I was actually working so might have missed that opportunity unfortunately. Speaker 1 So the opportunity was there, you didn't take it. Speaker 2 Yes, yes, I, I guess that is the case that there was opportunity of going on a boat and renting a boat and going out on the lake. I was more alluding to the fact that none of the docs had a vote that we could just go on without paying that would. Speaker 1 Have another rural communities? Speaker 2 It is. There is a lot of other communities where the the docs will invite you out onto their boat or into their like private land or whatever and do fun activities there. Something like did not really have that unfortunately. So in terms of a day and or a week in something like it's very different every week we would do things like obstetrics, we'd follow the the family managed doc who's on low risk obstetrics to Red Deer and to do a 12 hour shift there either in the day or overnight. We would do a week at a time of internal medicine, hospitalist medicine. We do a couple days here and there of surgery every month and then Pediatrics a couple of times throughout the year as well. And then the rest of that time is filled out with urgent care or filled with family medicine. So we have a good spread of what we're doing week to week. And so saying what we do from Monday to Friday will look very different depending on the week of the month it is and the time of the year it is as well. And so it's really hard to give a synced answer to that. But generally we would start our days around 89 AM and we'd end our days around 5:00, 4:00, or 5:00 in the evening. And we'd be able to go home, do whatever we do over the weekend or over the evening, I guess, and then kind of start the day again every Tuesday afternoon or Wednesday afternoon, depending on the site you're at. We get our academic half days where we do Zoom learning with the program director or an invited guest on specific learning topics that were required to cover during third year clerkship. Speaker 1 Nice. So I feel like my answer to like what do I do on like a given day on like the track rotations is going to be even more long winded because it very much depends on what rotation you're on. Within that rotation. It also depends on what hospital you're at and what physicians you're working with, how your day ends up going. And you don't even really have consistent start times. It really depends on the rotation. Like right now I'm on my psychiatry rotation and we're starting at 9 or I start at 9:00 because that's when my preceptor starts. But even within like all of us, the same site, my classmate at the same site as me starts at 8:00 because that's when his preceptor starts and he finishes at like 10 in the morning. I don't finish until 2:00 in the afternoon. And within rotations, there's that variation as well. When I was doing my surgery, on some days we wouldn't start until 9. Like on my community rotation clinic days, we also wouldn't start until 9:00. But when I was at the trauma site, we would have to be at the hospital at 6:00 in the morning. So there was a quite there was quite a bit of schedule variation we'd. And literally anytime between like 12:00 PM and like 8:00 PM or not 8:00 PM, that's a bit much. But like 6:00 PM depending on like what the rotation was and like where and what we were doing, kind of going experience by experience. I guess I started on Pediatrics. And within that rotation, there's a lot of variation. We are, it is 8 weeks, but we're like 2 weeks each in different places. So I started on inpatient PEDs and we were in the hospital from like 7:00 AM to 6:00 PM basically kind of going around like checking on the patients in hospital and then discussing as a team together to manage their care kind of transition from there to a week of emergency. So we do get emerge exposure is not very much emerge exposure on the tracks. And then we did like I did a week of like subspecialty Pediatrics where I did like outpatient clinic and followed by more weeks of outpatient clinic for family Med. I mentioned that I went to a rural community. Speaker 2 I'm just going to interject here a little bit in terms of Pediatrics at the rural site for Sylvan like specifically we did one week in the hospital and then at some other .1 we can community as an outpatient. So get that exposure Pediatrics there. And when we're on for Pediatrics at Red Deer, we covered both the NICU and also the more adult, I guess pediatric population. And so we get an exposure to both at the same time. And then when we're outpatient, we do more of the generalist outpatient pediatric stuff. Speaker 1 Yeah, I'd argue that you guys actually get like better NICU exposure than we do. They changed it our year, but we only got like two days of NICU and at that point it's like kind of impractical for the doctors to involve us. Like they didn't even ask us to take notes on the patients because we did 2 days and we were at two different sites. So one day I think the goal was just to like watch a lot of women give birth. I I don't know why that was the goal given we have a whole obstetrics rotation. But yeah, one day I was just like ushered from room to room while women were giving birth. Just like, got to watch that for the day. I don't know that I really took away a lot other than to like be more compliant with my contraceptives. But we also did a day of 1/2, day of rounding at the NICU. So I think you guys actually probably got like better experience in terms of like actually being involved in patient care in the NICU. Speaker 2 Interesting that you bring up the obstetrics portion of it. We do have obstetrics at the Red Deer Hospital and we get to round with the low risk obstetricians, the family physicians that are on obstetrics, but we also work with the obstetricians who are on at the hospital as well. And along with that, we also do the evaluations of the babies after they were born. And so if we were more interested in Pediatrics, we would have the opportunity of maybe working a little bit more with the pediatricians after the baby is born. If they need to be further evaluated, resuscitated, we have that opportunity as well. And so that goes back again to my discussion about flexibility within the teaching. And so in terms of a longitudinal clerkship where you kind of follow the patients along. And so if we wanted to say follow baby 8 from birth and then they're going to the NICU, can kind of follow that patient to the NIQ, chat with the pediatricians about their care and then potentially follow up even the next day if we are in the hospital around that time. And so there's a little bit more of that continuity of care there. Speaker 1 Yeah, I mean, I can't really comment on like obstetrics rotations like in the city because I haven't done mine yet and I'm actually opting to do mine rural. So I feel like I'll have more of a similar experience to you on that. Kind of moving on to the next area, Let's talk about internal medicine. What was your exposure to like internal medicine, hospitalist medicine like? Speaker 2 Yeah. So for internal medicine, what Red Deer does is we go on maybe once a month for an entire week of the internal medicine slash Hospice medicine, a component of our training. And so we work with the same hospitalist, generally speaking week to week throughout the entire school year. So which is about 10 weeks roughly is how much we're with them. So we get to see all of the everything from a queue from consoles all the way to managing patients on the ward and potentially things that come in overnight as well. Although at Red Deer, we don't really do overnight call because the hospitalist gets called and it doesn't really make sense, as I'm told, for the Hospice to then call the student to go evaluate the patients and then they have to reevaluate the patients anyways. That just kind of defeats the purpose of learning overnight and prevents you from coming back the next day. And So what we do is we stay late until probably around midnight and then we'll come back in early next morning to kind of follow up on those patients. Now, we are fortunate enough at Red Deer to also have internal medicine as well. And so if students were more interested in, say internal medicine, which I would describe as higher acuity, more complex patients, then they have the opportunity of selecting or working with some internists throughout the year as well to have that additional exposure. And that's something that I reached out to the internal medicine team and set that up with the permission of the coordinator at the site. And so that's what I did for a couple of weeks closer to the end of the year to have that additional exposure to internal medicine. And so there's that, again, that flexibility in terms of identifying what you want to do and trying to find individuals in the community who are able to take you on to do that. Contrasting Internal Medicine and Psychiatry Training OK. I guess I can share a bit of my experience of internal medicine. So we do 8 weeks of internal medicine as part of the standard program, except we do those eight weeks all in a row, which I find to be a little bit of overkill. Like I think like by week 6, I was kind of like happy with internal. I was like oht, like I am, I guess kind of enjoying it. Like might be sad to leave. By week seven, I was like, Get Me Out of here. By week 8, I knew where all of the exits were in the hospital that I was at. So like if there were to be a fire, I would know the fastest way out. And I just remember having all the exits memorized and like really wanting to use them, but knowing that I wasn't allowed to. So I do feel like your experience of like more time but more spread out time is probably better. We had the preceptors rotate every week sort of like you. So we would have a different preceptor every week. Some of the preceptors would like come back though, like they do week one with us and then they'd be back for like week 5 or 6. So we got like some exposure to some of the same preceptors and some longitudinal exposure, which was nice. We also kind of spent eight weeks like in hospital with these patients. We'd come in the morning, we would check in on every patient, and then as a team we would like discuss and manage the care of that patient together. And that was essentially like every day of internal medicine. We'd like holistically look at like every system and every patient and every like, medical condition that they had and like, try to manage it essentially in hospital, which I do think like you get EU of A is very good for their exposure to general internal medicine like EU of A. Like I see it in the residence too, like, you know, like which residents have graduated from U of A versus like which ones haven't? Like I can tell or I could tell by the end of the rotation. And I think it's because like the track system does like such a good job of like drilling in like the exposure to internal medicine. So I do have to like give the track system that, although I don't think like you guys are unprepared either. Speaker 2 Yeah. And I think there's some benefits to following the same preceptors throughout those ten months versus having new preceptors cycle in, in and out because there's obviously different teaching styles, different learning styles once the students. And so that opportunity to have these different exposures to different ways of thinking about a problem can be very helpful, especially in a diverse population of students who are trying to learn at a different pace and different levels of learning. But overall, I think the track system does a really good job of teaching individuals what they need to know by the end of it. The other thing I think is important in terms of the ICC program is that because we are also spread out in terms of our learning, we may feel like we don't really know anything by halfway through the year, regardless of what rotation we're on. But that just means we're only halfway through our entirety of all our core systems. And so I think even by the end of the year, students will catch up eventually in terms of their learning and be able to really kind of accelerate their learning at some point throughout the year such that they can kind of do just as well as their urban colleagues. Speaker 1 Yeah, I think for me with that eight weeks of internal medicine, like I had a really steep learning curve during the first six weeks, but then I just kind of like plateaued at week 6. So it is like a lot of exposure to a lot of the same. And I feel like the track system really does a good job of like teaching you the essential skills you need to learn. Although I do find it's very site dependent as well. We have three sites for internal medicine in the urban system and I was at the Grey Nuns and I found we got like a lot more acute presentations and like presentations that were at the medical student level to manage compared with the other two sites where those patients were just more complex than had like a lot more things going on and maybe weren't as easy for medical students to manage. So I feel like even within the track system, it's really like site dependent what kind of experience you get. Speaker 2 Yeah. And you know, that brings up a different point in my mind actually about the track system versus the rural system. In terms of the track system, the physicians kind of have to be there and medical students and residents are just kind of an added thing onto their day. Whereas the roll system or the ICC system, physicians kind of have to choose to be willing to take on students. So they are generally people who actually are interested in teaching and interested in helping students understand and learn. And so I think there's a bit of a different perspective in terms of where the physician is coming from based on the urban and rural sites, in terms of how the physicians kind of approach students. Is that in rural sites, because the sites are actually independently running themselves without the use of students, I think it's a lot less service based. So students are there and encouraged to learn as much as they want about a specific patient. So if I had a really interesting patient that was really complex, I could say that I'm not going to take on as many patients this week. I'm just going to try to focus on this one patient where I don't know if that was necessarily an opportunity for you. And in urban centres, say like I want to kind of manage my list and tailor it to however many patients I want because of the complexity of my patients. Speaker 1 Yeah, I don't think we ever really had that. I think it was always like the preceptor would be like you're going to take three patients today or you're going to take this many patients and the preceptor would kind of tell us how many to take. I always personally felt like usually the preceptors would like give fewer patients than I felt I could take. But there would be other days when like we actually wouldn't divide up the list with the preceptor was very like preceptor dependent. Sometimes the resident would just come in and we would like split the list evenly between however many of us were there. So if there was a day when like a lot of people like weren't there because they were away or they were like post call or something, like sometimes I would end up with eight or nine patients, which was quite a few more than I wanted. But it was like really dependent on the day. Like we never had the opportunity to be like, I only want to take like this many patients. I found like in the urban setting, it was always very much like you're part of the team, like you need to do your part of the team and your role of the team is to see and manage and write notes on three patients. Speaker 2 Yeah. And I think that's very different from the rural experiences I had where I can go in and say, you know, I have these, I read these charts on this patient here. They're extremely complex. I wanted to take this patient on, but I think, you know, because of how complex they are, I want to only take on three or four other patients, whereas say week is pretty easy and pretty light in terms of the patient complexity. I could say that, you know, I'm willing to take on extra patients this week because I think I can do a little bit more and help manage a little bit more. And so the preceptor are always kind of accommodating in terms of that. And you're always free to speak up when you're feeling over a little bit overwhelmed in terms of the patient lists or complexity. And they're always there to message and ask for help should I need it. So I think it was very encouraging in the rural community to learn especially internal medicine. Speaker 1 Again, I will beg to differ that that is rotation dependent, which I think can segue into like our next topic as well, like comparison of exposure. Although I feel like I've already won this section of the debate because you said that your site had no exposure to psychiatry. So you came to the site where I'm currently doing my psychiatry rotation. So let's talk about psych exposure on kind of both. So I am currently doing my psychiatry rotation at the University of Alberta Hospital. And my preceptor actually like lets me take on patients. And she's like, oh, do you want to like take on the management of like this patient? And she's like, let's start with one. And then I'm like, actually I, I just want to manage them all. Like they've been here long enough. Like I know them, like I want to see them and manage them and just do it all. And she's very like flexible in terms of if I said I only wanted to like see and explore one patient, like she's willing to let me do that. And I find like with psychiatry at least like the rotation at the UAH, there's no residence there or there is a resident, but he's not working with my preceptor. And it is very much just like you are there as like an adjunct to the preceptor, but they can like function fine without you sort of thing. So we are very much encouraged to like pursue external opportunities. Like next week I'm going to do a day of forensics at like a different hospital. And then she's just going to like see all the patients and things will function just fine without me. And she's encouraged me to like explore other opportunities that the hospital offers as well, like ECT, sleep clinic, just various like other aspects of psychiatry that are different from inpatient psychiatry. And my preceptor is very much like her own functioning unit and just kind of encourages me to like pick and choose and explore. So I think in many ways like that rotation is like more similar to how ICC. Speaker 2 Is yeah, definitely sounds like it. In terms of my psych exposure, mostly it was through the couple of days I did at EU, Yeah. And then also through obviously the family medical clinic when we have longitudinal follow up with patients with psych psychiatric conditions. Other than that, there was actually not a whole lot of site theatric conditions rolling through the door. So I didn't see a lot of acute presentations of mania or psychosis and things like that. And so definitely a little bit more lacking in that regards. But also I want to do a general internal medicine and so psychiatry is not really in the vocabulary of my future goals and so probably. Speaker 1 What if your patient has urinary incontinence and schizophrenia? What if he's hearing voices that are telling him to like hold on to his pee and that's why he has urinary retention? Speaker 2 After I've ruled out all the organic causes, it would be a console to psychiatry. Speaker 1 Ah, but if he has like both things though. Like he has a kidney stone and there's voices telling him to like. Speaker 2 Then I would fix the organic conditions and then consultant psychiatrist. Speaker 1 Don't want to touch it at all, OK. Speaker 2 You know, it's really funny that you bring this up, but as someone who's done a lot of internal medicine and who's done a lot of also community medicine and family medical clinic. So I'm really comfortable with starting like antidepressants and some of these medications. But when I'm on internal medicine, I would make the suggestion and saying, oh, why don't we try Citrulline? And the interest on call or on my stack would be like, that's really great suggestion. Let's chat with psychiatry about that. And so I feel like that's just kind of how my life is going to be in the future, is that if there is a psychic condition, I am just going to be consulting psych. Speaker 1 Fair enough. I'm, I mean like my experience on psych is like very much like the same. Like anytime any of the patients have a medical concern, it's like consult the hospitalist. Like on my, my second day of the psych rotation, actually, I was chastised by my preceptor for like, or I was like seeing a patient and then somebody had like pulled her aside for a question. So she came in halfway through the interview. And when she came in, I had like an image of the Bristol stool chart pulled up. And we were going through like the different types of your poop. And like, how like if you're having Constipation, like you shouldn't like stop taking your laxative, Like when you stop taking when like you're not constipated and going over like blood in the poop and all that. And she came in and she was like, what are you doing? And then she was like, anytime there's a medical concern, like we refer to medicine and I'm like, oh, but like I could help. But he can point out like his poop in pictures, like it's great. So I think this is like being a medical student and seeing it where we get to learn about all the areas and having done like internal medicine before and like just finishing general surgery prior to that, I was in a position where I was like, I know how to manage this. But then seeing like as like you practice more as a physician and you see less of that. Like I can see like why you would be like less comfortable doing that. I think it also depends on like what the standard of practice is though, because like I will argue like if you are in a rural area, like you're probably going to be like doing all the things. Like I, I'd be willing to like bet money that like if there was somebody with like depression or anxiety and Red Deer, like you're not consulting Psych like you're or not like Red Deer or Sylvan, like, like you're not consulting like you're just like prescribing them stuff 1st and then consulting psych later. Speaker 2 Yeah, I think that would definitely be more so in the community. If you're at the Red Deer Hospital, internal medicine especially would want to consult site for management of say even acute depression and all of that. I've definitely had preceptors tell me that they're not comfortable with starting these SSRIs and to chat with psych even as an outpatient for starting that referring to the family physician to starting those medications. And so I think it is definitely maybe more of the culture of the area or the region or even of the specialty in terms of what physicians are comfortable with managing. And again, this goes back to the training, right? They don't have a lot of psych exposure in terms of their patient population. And so it's a skill set that kind of gets lost over time in terms of diagnosis of of these different psychiatric conditions. Similarly, in psych, you don't have a lot of these exposures to managing all these different other conditions such as blood pressure, diabetes, and all of that. And so that kind of skill set gets lost over time in terms of your practice. And so we become less and less comfortable with it. And as a result, you become a little bit more skeptical, skeptical of your own. Ability in terms of managing that. And so you want someone who's a little bit more of an expert in terms of helping manage that and making sure that you're doing something that is not going to be detrimental to your patient. That's not to say that if you're a physician that says that, oh, you know what, I feel comfortable starting search really, or I'm comfortable with managing their diabetes, then that by all means that is something that you're able to do that is within your scope of practice as a medical graduate. But again, that depends on the comfort level of the physician that's practicing. Diverse Experiences in Surgical and Family Medicine Fair enough. Well now I guess I've heard it from your mouth that anytime anyone comes to you with a psych condition, you're just gonna refer to psych. Speaker 2 Yes, and as a person that's going to be going into internal medicine psych, please do not consult internal medicine for everything. Speaker 1 Well, I feel like the arrow should go both ways. Speaker 2 I will disagree with that. Speaker 1 Fair enough. OK, let's talk about surgical exposure on ICC. Speaker 2 Yeah. So surgery exposure, I think he nice to see. It's what you say site dependent, but at something like we're fortunate enough to have Red Deer as a large hospital or we get that exposure to surgical specialties. So every 3rd week, every Wednesday of that third week, we'd be on surgery. So we'd start around, I don't remember 67 AM round with the surgical team observe the on call surgeries for that day and we're technically on call overnight, but rarely are there things going on in Red Deer overnight. And so we're usually sent home about 10:00 that evening to kind of do our own readings and learnings and then come back and the next day to whatever other clinical application that is not surgery that we have. And so we get kind of the exposures of all the cute conditions of general surgery from the Coles to the applies to the Bower sections to the Crohn's diseases and all of that. One thing that I think we do not get as much exposure to that you might get a little bit more in the city as colonoscopies and all of that. Sometimes those are carried out by general surgeons depending on the community. And so if there's maybe a little bit of a GI taste to you're interested in, that might be something that maybe a little bit absent. Speaker 1 I beg to differ. Actually. That's just like a thing that's absent in Sylvan Lake. Like I feel like it really depends on the community and on the surgeon. So I did my rural family Med in Cold Lake, but the surgeon there also covers Bonneville, which is an ICC site. And during my real family Med in Cold Lake, like I was pretty upfront with them. Like I told them like I wanted to do rural and I was surgically oriented. So they were like, do you just want to like hang out with the surgeon for three days a week? Like he's here for three days and then in Bonneville the other two days? Like you can do family Med for two days and then like surgery for the other 3. So that's pretty much what I did. And I actually ended up dropping those three days down to two days because he would have one or a week and then two days of scopes every week. Like it was a lot of scopes. Like I, I realized very fast that I did not need to see two days of scopes every week. One day of scopes every week was already like still quite a bit, but it was nice. Like the surgeon there got me involved. Like I was doing biopsies. I carried like a massive like mass, like out of the colon, like I had to like drag it and hold on to it. It was an experience. He let me drive the scope for a bit. Yeah. I was just like very involved in all of it. So that by the time I got to my urban rotation, I could have like requested to do scope. So when I did my urban rotation, for the first three weeks I was on community and they just kind of planned out my days for me and I wasn't scheduled to do any scopes. However, I probably could have like requested it and swapped it around. But I was like, I, I've seen enough like, and I was very involved in it. If I were to do this in an urban community, like from what I've heard from the masses, like you just stand there. And I'm like, if I saw it a bunch of times and was doing it like, I don't really want to just stand there. Like I think I've gotten the experience. And then for my trauma site rotation, we could actually pick what we wanted to do each day. And there was usually somebody doing scopes every day. I just, I never picked it. So I feel like it really depends on like what real site you're at because I got a lot of exposure at my rural site. Like people would ask me like, oh, do you want to do any scopes? And I'm like, I did 12 days of scopes on real family bed and they're like, what do you mean you did 12 days of scopes on real family Med? So I feel like it really does depend kind of turning to my surgical rotation now. As I mentioned, I had kind of like 3 different opportunities to explore surgery. I did a trauma site rotation at like a really big centre in Edmonton. I did a community rotation at a smaller site in Edmonton. And like the trauma and community rotation are part of the standard like block rotation. And then I got a lot of surgical exposure on my real family bed. So I feel like if somebody interested in surgery like it, doing the tracks was a really nice like way to expose myself to like the whole spectrum of sites. So while I was doing trauma at the trauma site, we would start at 6:00 in the morning. We'd do like rounds on the patients, just like check in on everyone for the first like hour and a half. And then from 7:30 to around like 3 or 4 would be the operate, the operative room cases where we get put on different teams. So at my site, there were three teams. There was the colorectal team, the bariatrics team and the cancer team. I was put on the bariatrics team, completely random. I would have preferred like either of the other two teams, but like everyone on the bariatrics team was nice. It just like wasn't really my thing, but got to like assist with a lot of surgeries, got to observe there are more residents there. So especially with the bariatrics, like it's more advanced. So I found that I was doing more observing than actual like learning and doing. And in many ways I'm glad I like got to do it in the order that I did, where I went from being like very involved to like medium involved to like less involved because I find that the bigger the site you're at, the more you have to like prove yourself. Like at the trauma site, I was one of the only students. It was actually like inserting like ports into the patient for the camera because like I was real confident and was like, I did this a whole bunch of times for my rural family medicine And I did and they let me because I said that I, they let me do it a bunch of my community site. And then because I got to do it a bunch of my community site, I got to like do it a couple of times at my trauma site. So I do find that like order did matter to me a little bit. And then also at my trauma site, we would do like clinic days again, like somewhat more straightforward, like seeing outpatients ending at like 3 or 4 each day. For community, it was a little bit more varied. We also had minor procedures kind of thrown into that mix. And we also had we had the option of doing scopes and we also had the option of like exploring like breast and thyroid surgeries, which is something that you guys might have, might not have known. Speaker 2 I don't, I know there's these physicians at Red Deer that do breast surgery, but it was not something that I was a interested in, nor was something that I actually reached out for by feel. If you were really interested in breast surgery for whatever reason, then it would be something that you're able to kind of request and work with the surgeons that do that. And I think that comes again to the idea of being flexible and identify things that you want to see and want to learn about. I'm not actually sure if we do any ENT surgeries in. Speaker 1 General Surgery. Speaker 2 It is both actually depending on what they're doing. So I don't think any of the general surgeons, as far as I know, do thyroid at Red Deer. I think it's mostly the ENT docs that might do it there. There is also orthopedic surgery there and also the urology and obstetrical surgery, gynecological surgery as well. So if you were, say, interested in those during your time in Red Deer, those are things that you can always request and see if you have time for. Speaker 1 Yeah, I do find it's very like psych dependent with all of that as well. Like I didn't really get any exposure to like breast and thyroid when I was at the larger trauma site. It was actually at the community site where I got more exposure to breast and thyroid. And there was really only like 1 physician there who did thyroid. And so you just really had to like luck out if you were assigned to them to like get to see that type of surgery. So again, like very site dependent. We also, you were mentioning hours, while we do finished like 3 or 4 most days I'm at the trauma site, we would do overnight call and see like any consults that came in. If there were any like night cases that went on, we would get to be involved in those and we would stay overnight and get like the next day off for our community site, same as you, we'd stay until like 10 and there was just always something happening. Like by the time all of the cases were done for the day at 3 or 4, there would already be like 2 cases booked for the evening. And then I would just spend like the entire evening doing like bonus operations. And it was really fun in cold leak. Like things were a little bit different. The surgeon would either have like a, we'd start at 8 and the surgeon would either have a morning full of scopes, like morning, afternoon full of scopes or a morning and afternoon full of like smaller procedures. He also only did laparoscopic surgery. So by the time I started my surgery rotation, they were like, have you seen like a hernia repair before? And I was like, yeah, I've seen like 10:20. I've never seen you do it like open like this before. I've only ever seen it like with the laparoscope. And they were like, oh, weird. OK. But yeah, he did everything kind of with like a laparoscope, which is like, for our listeners that don't know, a camera that goes like, inside the body so you can operate from inside instead of the outside. You should watch videos on YouTube. It's very cool. So saw a lot of like procedures which require that type of equipment like appendixes, gallbladders, hernias. I also got exposure to a lot of like urology type procedures like circumcisions. Sam and I were talking before the episode about how I watched this surgeon do a circumcision with a bone saw and was very impressed and like thought that was the proper way to do it. And then like told a senior urology resident all about my experience thinking that this was the right way to do it. It is a unique way to do it is all I will say. And in addition to that, also like vasectomies, the surgeon in Cold Lake didn't do it, but I know a lot of like surgeons in rural areas do do C sections. And then the surgeon in Cold Lake, he also did minor procedures. So he would do like some stuff that fell in the realm of plastics. Like he would repair your carpal tunnel. He would repair your like doobie trins contracture, which is like a really niche like medical condition where like your pinky finger is bent and he would essentially take on the role of a plastic surgeon and like do all of that. And I would get to see and help with all of that. And we'd usually finish around 3 or 4 and then he'd like launch right into his clinic after. Like he would start clinic at 3 and end at six and then I would go home When I was in Cold Lake, like I opted to be on call every day because nothing ever came in usually. And like they also stop operating at 10. Like they shut the OR down at 10. So like either way, I wouldn't need to take a day off the next day like for call. So that was my exposure. I got a lot of exposure. Speaker 2 I, I don't think they actually shut down the ORS at 10. I think they just stopped taking additional cases in case an emergency comes in. So it's really similar to Red Deer because the anesthetist stays on overnight and so they don't want to be tired, say if there was a extremely urgent case that needs to come in to be done. And so they would still likely spin up the OR for that reason, but. Speaker 1 Nobody told me that like this surgeon there said like if the appendix appendix has comes in after 10:00, it can wait until 8:00 AM the next morning. And I was like, oh. Speaker 2 Alright, because that's a because. Speaker 1 I'll be more urgent. It got like sent to Edmonton or something like we didn't deal with it and called. Speaker 2 Like I think it depends on the urgency of the condition, right? So there's different classifications and I don't know if we want to really get into that here, but there's things that's easier, E 6, E 72 and all of that or it's 72. And so appendices fall a little bit late lower down. But if there was an E0, so like something that's traumatic like splenic rupture, for example, that you're not going to send them to Edmonton because that's way too far and way too long of a drive them to see Belize. And so you would still spin up the OR operate on those patients. And that's why you need an assist that's not sleep deprived after being awake for 20 hours to do those kind of supporting acts. And also the surgeon needs to be awake enough to actually do those operations. But yeah, so I think that's kind of the case in terms of these rural communities, they actually have built in fail safe so that they don't have sleep deprived surgeons and operating when really urgent cases come in overnight. Speaker 1 Interesting. I do want to clarify for our listeners the ease because like I only very recently learned this. So like a lot of our listeners who haven't started medical school, like might not know, I like to think of E as like estimated amount of time that can go by until something really bad happens and then in hours. So like if a case is like E0, like no time can go by, you need to do something right now. Whereas if a case is like E 72, like you could wait three days before something really bad happens. So like, small numbers are bad for our listeners. So let's like kind of round things out by comparing exposure to family medicine, because I'm sure you got a lot of that out in Sylvan Lake. Speaker 2 Yeah. So ICC is basically around family medicine. So any time that we're not doing something more specialized or a different specialty there, we'd be spending doing family medicine. So the exposure that I had to family medicine was very, very varied. There was things from community, outpatient community to urgent care centres to obstetrics. There wasn't as much surgery that the the family physicians were doing and so we didn't see a huge amount of that. My preceptor was also especially interested in Women's Health. And so I got a lot of exposure to Women's Health from everything from contraceptives to IUD insertions to Nexplanon insertions to menopause and pessaries and all of that. And so I had a really diverse range of Women's Health exposure in my rural community. Fun fact that sometimes the internists will actually not the internists, I should say, sometimes other family physicians especially in urban settings don't actually do insertions of pessaries and all that and they actually refer to obstetricians or gynecologists to help with that. And so it is a bit of a unique skill to kind of size and be able to help insert the pessaries and help with the cleaning and maintenance of that as well. Speaker 1 We had a guest here like a couple of weeks ago for whom like, that was his specialty. Like he's internal medicine, like geriatrics, but his specialty was like continent. So a lot of it was like custom pessary use for women in need. Speaker 2 Yeah, there's a lot of different shapes, which is actually extremely interesting in terms of the the kind of math and the physics that kind of goes on in terms of all these different shapes. I'm a bit of a nerd and so I like all those things there. Speaker 1 Others It's your version of the Bristol Stool Chart. Speaker 2 Actually, I love the Bristol Stool chart. It is something that I bring up almost every single conversation on my internal medicine consult. Speaker 1 While our listeners look up the Bristol Stool Chart, you can use it. It's like a pictorial representation to classify your poop. 4 is good, anywhere too far from 4 is not great. Speaker 2 It goes from zero to seven. Oh, sorry, one to seven. And so you can kind of kind of know at that point the strings. Are there other things? Like I think that was really well done in terms of Sylvan Lake is again, that graduated ability to do independent tasks. So I got really comfortable with suturing because I did a lot of suturing both in the community outpatient clinic and as well as in the urgent care setting as well. I also had a ton of exposure to doing PAPS and graduating from PAPS, helping with IUD insertions and also helping with endometrial biopsies and all of that. And so a lot of, well, I would say a decent amount of hands on experience from what a family medicine physician can do in terms of their practice. Speaker 1 Wow, yeah, that is a lot of diverse exposure. I feel like, again, it's very like site dependent what kind of exposure you get to family medicine. I actually didn't do like an urban family medicine rotation, but from what a lot of my peers have said, it's very much the stereotypical like 9 to 5 clinic, 15 minute appointments, kind of all outpatient. A lot of it is medication refills. It's something that like I found wasn't really my vibe. And I don't know that a lot of like the students who got to have that experience really enjoyed that experience. For my rural family medicine, I guess like sticking just to the clinic 1st and we can discuss the emerge aspect later. But for clinic, we mainly did at my site, we did walk in clinic. So they really stressed with us. Like we didn't really know what we were going to see day-to-day. It was a good mix of like a lot of different things, but we were very much, it was very focused on dealing with like one patient, one issue. Like they really did stress that to us a lot. So it was very good practice for our like focused history taking. You guys probably got more exposure and we added to the whole like general family practice aspect where you ask about everything that they have going on and all of their all the patients like longitudinal stuff as well. We got a lot of exposure more so to like acute conditions. We also had like variations of things. But yeah, we mainly did like walk in clinic. There was a walk in clinic every day. On top of that, we had the opportunity to go to the reserve and do like a clinic on the reserve. And like, I thought this was really cool because this is something that like I might potentially gonna do in the future, but it was like a mobile clinic. Like they actually don't have like a fixed address for a clinic. Just like once every two weeks, like a physician, like drives a vehicle of medical supplies up to the reserve, parks the vehicle people line up and that's the clinic like right there, like you're working out of your car. And like, I, I don't know, like I thought it was pretty cool. Speaker 2 That almost sounds like the old traveling physicians where they'll like, yeah, right out on a buggy or like on horseback with all their tools that they need and see patients. And I think that's a wonderful way of kind of getting really good at practicing medicine with not a lot of resources. And that's, you know, we talk about rural community, but we also have to also think about remote communities where they actually have even less access to these goods. So things in the north where if you want anything that's a little bit more specialized, you're flying to Edmonton or another major centre to get those. And sometimes, you know, medications aren't actually. In the local pharmacies actually flown into local pharmacies for you. And so this is going to kind of skill set that some physicians need when they're practicing in these remote communities as well. Navigating EMR and Choosing Your Clerkship Path Yeah, that was actually a thing that was true with us. When we would come, we wouldn't have the medications with us. That was like an extra step of the process. And I almost wonder like how they did it. We would have a conversation if anybody did need medications, like when we would write their prescription and we'd write it by hand. I got very good at writing prescriptions by hand, but we would write it for them and we'd be like, are you able to get to the nearest city, which was Cold Lake, and like actually pick it up yourself? And then if they weren't, we would come back in two weeks with their prescription for something like strep throat. Not great, but that is what we did. Speaker 2 Yeah. I wasn't directly treating this patient, but when I was back in urban setting, I was seeing a patient, I don't remember exactly what the condition was, but they're from northern Canada, I think in somewhere, none of it. And their nearest pharmacy was actually a flight away. And so in order to deliver their medications, they actually have a plane flight into their community and deliver it to them there. And so it was a big challenge in terms of making sure that the medication is delivered on time and correctly and accurately there and there's no breaks in freezing and all that. Speaker 1 Yeah, it's, yeah, I definitely like, really enjoyed the experience of like going out into a remote community because I found it was very much like practicing like basic medicine. And yeah, I had like a similar opportunity when I was like out in BC. Like I got to do a one week like elective experience in rural BC and just like exploring like both surgery and family medicine. And they don't have like an electronic system to store everyone's medical records. Like we were writing everything down on paper. And I actually found it to be like really good in terms of the learning, not great from a family physician perspective. Like everyone had like a massive binder and that binder was from like the last five years. So like anything that happened to them before that, like we didn't know. So it wasn't great there, but I did find it was very good for me in terms of like learning what to ask as a clerk and like how to take notes, that sort of thing. Which actually leads me to the next question because I've there was a skit about it this year, people making fun of the ICC students having no idea how to use like the electronic medical record logging system. To what extent is that? Speaker 2 True. So I think it was true mostly in my ear because hospitals around Alberta were still rolling out Connect Care, but I think now that we're done wave 9, which is the last wave, all hospitals and all AHS facilities now use Connectcare. And so I don't think it's actually as much of an issue now and moving forward where there are different ways of having electronic medical records and those medical records being kept. For me, I was fortunate to be at Red Deer, which was one of actually the first couple of ways because it's a large medical centre. So I got really good at using Kinect care and learning about how to use net care, on optimizing all of my shortcuts and all my templates because I had the time to develop those and making them all really nifty for when I came back into the city. So in terms of the emmers, there's not as much of A learning gap for me as there was historically for most IC students. Speaker 1 Fair enough. Again, I think it's also like very site dependent because when I went out and did my real family Med, like I did it a few months ago, they were probably not on wave 9 at that point. I'm the hospital. So like my family Med clinic was a clinic within the hospital, like The Walking clinic was within the hospital, but all of the hospital and like all of the patients like the inpatients were on Connect care, but the clinic like wasn't the clinic was on its own like self functioning system that like I didn't know how to use. Nobody expected me to know how to use. There was another clinic we could go to that across the street that was on a different system that I also didn't know how to use. So I wonder with you guys, in terms of your family Med exposure, I feel like you get more exposure. Does that mean that you get less exposure to Connect Care compared to the individuals on tracks? Speaker 2 So I think for family medicine, because family medicine is privately run, they actually not part of Connect Cares rollout. And so regardless if you're in the city or if you're as remote as you want to be, there is likely a different electronic medical record for keeping those pieces of data. Physicians can pay to actually be added on to Connect Care if they wanted to, but it's quite expensive from what I've heard. And so most offices are like to have their own Emrs for that reason. And so I don't think it's something that's going to change in terms of your Cold Lake experience where the clinic within the hospital is likely still run independently from the hospital. And as a result, they have their own EHR systems. And so I don't think there's actually any differences in terms of how much exposure I had to Connect Care. I saw it on all my 4 rotations aside from family medicine, and so I was pretty well acquainted to it with it by the end of in my third year. In fact, I think I actually learned a lot of things that people in the city may not know, such as how to look up the snap board for the ORS or looking up the grease boards for the obstetrics ward and all of that. And so things that can be. Speaker 1 Done say I don't even know how to do that. Speaker 2 Yeah. And so things like that I pick up because I see all these different people and they have these all these cool things. And I become friends with the surgeons and they're like, oh, yes, you should definitely use it this way. And I'm like, I did not know that. OK, that's good to know. And I bring that back to the city. And you know, when I see people struggling trying to figure out which or they're supposed to go to and what the plan is for the day, like, you know, maybe you should try to use the snap board and it's a great tool to use and to know what's going on. I. Speaker 1 Think you were the one who told me this. You were like, why are you like just staring at the screen waiting for something to happen? Like use the snap board. And I was like, oh, I'm just used to there always being a screen that I can stare at and like, wait for something to happen. Speaker 2 But that also really ruins your coffee break because you're staring at a screen instead of going down to get coffee. Speaker 1 Or I could have just already gotten coffee and had now staring at the screen. Speaker 2 But who wants to be in the OR rooms when you don't have to be? You could be enjoying the sun of the outdoors. Speaker 1 Again, site dependent. Some sites have like an or lounge which is nice where the screen is like it's. The screen isn't usually in the OR. Speaker 2 OK, fair enough. Let's move on to the next point there. Speaker 1 Let's do that. So let's talk about who would you recommend ICC to? Like what type of student would you recommend ICC to and who would you not recommend ICC 2? Speaker 2 Yeah. I think ICC is definitely for individuals who I would say are self-directed learners first and foremost. These are individuals who can identify what areas of learning they want to have, what areas are their weaknesses and kind of help tailor their own learning opportunities within ICC program to those deficiencies and those interests. So people who might have interests, maybe that's tangential towards the core rotations and have opportunities to explore those. As I mentioned, anesthesia was something that I was initially interested in. And so every time there was a surgery going on, I'd go in a little bit earlier and chat with anesthesiologist and say, OK, I wanna help with intubation. Do you think that's something I can do? And nine times out of 10, they'll say, yes, it's something that you can do. And so I would help with the intubation. So I had a lot of exposure actually to intubations there. If I wanted to explore something maybe a little bit more tangential, say sub specialty of medicine or subspecialty of surgery, I could do those and have those opportunities. But those are again a little bit site dependent. Storm was available in terms of expertise at those sites. And so being able to direct your own learning in terms of your goals and your interests is really important there. Secondly, I think it's mostly for people who might be a little bit more interested in general medicine such as general internal medicine, family medicine, general surgery, maybe even obstetrics and things like that because of those kinds of exposure there. I think for specialties that require a little bit more competition where FaceTime with staff members of those teams might be more important, such as ophthalmology, dermatology, radiation, sorry, radiology or even derm dermatology. That's, that's the one I was thinking. I was like I think I'm missing 1 dermatology the. Speaker 1 Acronym is Rd. Sam, the road specialties. Speaker 2 Whatever, So if you're prior to those, then it might be more important to stay in the city and have those FaceTime with the staff so that they can recognize who you are and know that you are committed student to their specialty. Whereas people may be able to do those specialties even outside of their core or within their core rotations, they may not have that kind of same merit as having recommendations from those from the city. Other benefit would be that shouldn't be overlooked for ICC is that electives are by nature at the end of their third year or as in an urban track, depending on the track you're on, the electives can be anytime within the year. And sometimes it might be the first thing that you're interested, first thing that you do and your your specialty is pretty competitive. And so you wouldn't be necessarily getting that reference letter from the start of the year versus ICC you'll always have at the end. Speaker 1 Fair enough. You raise a lot of good points. I, I would kind of echo those points. It really depends on like what you want to see. And I would argue if you're interested in something like emerge or anesthesia in the regular track system, you don't get that exposure until your fourth year unless you do a few electives. But you're essentially waiting for a year to get that exposure when you could be getting the exposure throughout the year. So if that's something you want to do, highly recommend ICC. Again, for like if you're interested in family medicine, you'll probably get more involved exposure and more longitudinal exposure than you would otherwise on an urban rotation. And that's kind of like the bread and butter of family medicine. Again, probably would recommend ICC. People, I would not recommend ICC 2 are any specialty which like with the flip of a coin, like will I see this specialty in like half of the rural communities on this list? If the answer is no, probably don't want to do ICC. So if like you're thinking at like the decision point in second year, like I really want to explore neurosurgery, Well, you're you're kind or no, there is no neurosurgery in Red Deer. But yeah, like probably not the best idea to go to Sylvan Lake if you want to explore neurosurgery or like cardiovascular surgery, anything which like requires you to be in like a major urban centre. But again, I think like both programs are good options and it really just depends on like you what you want to do. Speaker 2 I'm actually going to disagree a little bit on the sub specialty surgeries. Actually, I think that ICC could prepare one really well for those special specialty surgeries because you have more interactions with the physicians that the general surgeons. So you get a little bit more experience and exposure there. And so you build up that confidence so that when you come back in to the city for your elective time, you're able to do those and kind of get a better start. Whereas if you're in, say, the urban stream, you don't necessarily get additional exposure to thoracics, neurovascular surgery or cardiovascular surgery in your third year. Speaker 1 You did. Speaker 2 I mean, you don't, right, you don't. So that's kind of the point is that you kind of start and end up in the same amount of exposure at the end of your course. It's really where the elective time where you get to really shine. And so if you have an entire year of surgical exposure and get really good at inserting ports and closing and all that, then you can start taking along a little bit more responsibility elective time to in those specialties and kind of impress preceptors in that way. Speaker 1 Fair enough. Point well taken. So let's talk a bit more about like the academic side of things for ICC for us and the track system, we'll do like 6 or 8 weeks of a rotation and then we'll have an exam at the end and then that's it that's done until we take a cumulative exam at the end of 4th year. Academic Strategies and Rural Clerkship Living For you guys, you have a bit more time between your assessment. So my question for you is, what do you do to stay on top of your studies and what challenges did you identify or were there any like gaps in your knowledge? Speaker 2 Yeah, for sure. I think one thing to not do is go skiing every weekend or going out to party every weekend. That is very easy to do because you're. Speaker 1 Rural Alberta you can party every weekend. Speaker 2 Depends on where you go and if you know the spots. So I think for for for me, I'm a bit of a nerd, so I did a lot of Anki cards and I did a got a practice bank from Reddit that was used for the USMLE, which I thought was pretty similar to what I would be expected to know for the MCC. And so that's kind of what I used to prepare myself throughout the year. And I set goals for myself, how many cards to look up and review. We do also continue to have academic half days where we have the key teaching points presented to us in terms of didactic slash glish manner. And so we have those opportunities to learn about the important topics that we're supposed to cover as well. In terms of assessments, we only have two major assessments and one formative assessment. So we have in February the formative assessment, like an actual MCQ formative assessment and then also AUS key as well. That's all formative kind of assess where we're at and help us identify gaps in our terms of our learning. And then we come back in June at the end of ICC to do our final exam, which is all MCQ and then also the key as well. And unlike the ones that Jessica here is going to be doing in terms of OXYS and final exams, it is going to be a smattering of everything that we are supposed to know. So questions from obstetrics, family medicine, psychiatry, surgery, Pediatrics are all kind of Fair game throughout the year. And we got get tested on that in terms of our final exam in OSKI at the end of third year, which is going to be actually a really great kind of similarity to what we would be expected to do in fourth year as well. And so, yeah. And so I think in terms of preparing for that is kind of being on top of your studying from a day-to-day basis, kind of pre reading around those academic half day content and identifying gaps in terms of knowledge with those with those academic half day teaching sessions there. And then just continuously reading around patients and patients that you see that are interesting or patients that you may have mismanaged and based on what what you did. Speaker 1 Did you find that like just being in a rural area that like this theory of what you're supposed to do in certain cases and like what you would actually do in that hospital ever differed? Because I found out a lot in Cold Lake. Like an example is like when I was working in the emerge, like we had the CT head guidelines. Like what kind of injury do you have to use? Like have to get AC T of your head. There was a big X through the entire guideline that just said like no RCT for next two months. Send to Edmonton if head injury. Speaker 2 Yeah, I think that doesn't disregard the fact that there is a guideline. It just says that there's no way of doing it immediately. And I guess that comes down back to practicing in a rural community and a rural community where you don't have those access and being really good at your physical exam and history to unify those key features of when to send someone out to a major centre for those investigations. I think for for me, in terms of Sylvan Lake, we had really great preceptors that are very guideline based and did a lot of teaching around those guidelines. So I don't think there's a lot of gaps in terms of what I was taught or differences in terms of, of what I was taught versus what I would be expected to know on the on the didactic lectures. And furthermore, if I ever found something on the didactic lectures that I was saying maybe Doctor X, you're not doing this the way I think we're supposed to buy guidelines, we would have a discussion about maybe why they weren't doing it as per the guidelines or something that maybe they need to start doing as part of their guidelines as well. And so I think that kind of ability to give feedback to the preceptors as well is also really helpful in terms of helping future generations of IC students learn and be better physicians. Speaker 1 Fair enough. Now I'm gonna kind of leave this question with you. Since you've had the opportunity to do both ICC and the regular tracks. Now that you've done that in fourth year, which do you like? Did you like better like gun to head if you could only pick one? Speaker 2 I think I'm going to do a bit of a cop out answer First here is I think both the rule and urban settings have their own merits. Speaker 1 Ground ahead. You can only pick one. Speaker 2 You know, I'll just eat the gun. I don't know, but let's, let's let's talk a little bit about what I think the the strengths of each one would be to start off with, I really have no regrets of doing ICC aside from maybe missing midnight in my third year. I think everything else was really good. It was great opportunities for learning, great opportunities kind of to self direct my learning a bit. And in terms of coming back to the city, I think there was an abundance of resources and experts and I think that specific subject matter knowledge was really important to help round out the knowledge that I already had from ICC. And the fact that, you know, the operational day-to-day from a city to versus a semi rural site is quite different. It was also some interesting contrast to to see in terms of what I would choose, as you say, gun to head in 3rd year, if I were to choose between a urban rotation versus the NYC rural rotation, I would choose rule again, just because I really love that self directedness of that learning ability and ability to regulate my own learning and look for interests and identify those interests and learn on those interests. And that's kind of person who I am, and being able to do that freely is just something that's natural to me. Speaker 1 Fair enough. I would just like to add on the point of like you mentioned, like missing like midnight or missing like events that are important to you. That's not a thing that's unique to doing a rural rotation for ICC. Two of my friends like also missed midnight or I missed like other events that our class was doing while on urban rotation just because we happened to be on call that night. It's not a thing that's unique to being in a rural community. Like you will miss events during clerkship because you are on call regardless of where you are doing your rotation. Speaker 2 I would just say that in rural community, it's a bit more challenging making the trip trip back to Edmonton. And so there's probably a little bit more missed out opportunities throughout the year because you're not right there and it's. Speaker 1 If you wanted to, you could. Are you wanted to you would. Speaker 2 I I guess, but say if it's during a weekday, you're hanging out with friends, it's not practical to drive 1 1/2 hours to go and stay for an hour and 2 and then drive all the way back, right? If you're in say Peace River where it's a 5 hour drive, that's again not practical to drive 5 hours to do a one event. You may drive back to see the weekend and do some things over the weekend there, but not just an overnight kind of situation there. Speaker 1 Fair enough. Yeah. It's interesting to hear that like you would choose like the rural again. And I think that's something like very insightful for our listeners to hear as well, like especially after you've done both. How did you find the transition to clerkship was like on ICC? Because I know on tracks it's really dependent where you start. Like some people are eased in and some people are just kind of like thrown in cold. It really depends. Speaker 2 Yeah. So I think the benefit of ICC is that everyone around you that is a student is starting at the same step. Generally in ICC, you're either in a community with two to three students for the most part. And so all the preceptors know you're a new student here as green as they come in. So they ease you into it. I remember that when I started my first week of Hospice medicine, I would take on only two to three patients because it took me like half a day or a day to kind of get through them and kind of read their charts and do all the background digging in terms of their hospital course, come up with an idea of what to do and kind of fumble my way through all that. And, and the preceptors, they're all really accommodating because they're able to see all the patients on their own if they ever needed to. And so it is very much on me to do as much learning as I can there. And they help guide me in terms of how to strategize what I'm doing. And as I became more comfortable with it and remember at the end, I would be able to see a patients a day no problem quite easily. And so that kind of progression is something that we see in ICC. And so for us to transition in was kind of eased in and everyone was really accommodating and understanding of that, that that we take a little bit longer as we start things kind of Peter out a little bit better and we're a little bit faster by the end hopefully. Speaker 1 Yeah, I do find in real communities as well, like everyone is more patient and like, they're more excited to see you. Also, I find it's like more common to see your patients just like, out in the wild and like, they'll say hi to you out in the wild, too. Sometimes they will tell you about their medical conditions, like in the grocery store, it's kind of wild. But yeah, they're very open. They're very like, glad that there's new faces. And it almost seems like they're all very like, thankful that you're there. Speaker 2 Yeah, actually, you know, that brings up really great points in terms especially of actually obstetrics. When I've heard that as a male in obstetrics, sometimes in the city it's really hard to get those experiences in the patient rooms and helping with the deliveries. In rural community, I think only been ever turned away maybe twice, maybe three times from being in that room. And so I think it speaks to the fact that rural communities are really appreciative of having student doctors willing to learn and wanting to learn. And so having those opportunities in not only obstetrics but also gynecology as well is really impactful for my learning moving forward. Speaker 1 Good to know. How about like rural lifestyle? So you mentioned you didn't get to go on the boat. What did you get to do in Sylvan Lake? Speaker 2 There's a lot of farmers markets in Sylvan Lake and there's a couple that run every week and I really like the farmers market food and so that's something that I did quite a bit of. They also have their own cheese production there. So Sylvan Stars, I go there on a routine basis to get the truffle Gouda. It is delicious and something that I am driving through Silver Link for whatever reason and if they're open, I would go and pick up some. Speaker 1 Didn't tell me about this one day that I came to visit you. Speaker 2 I don't know. I don't remember if it was open. Speaker 1 OK. But it was towards the end of your rotation, like we all came in like April. Speaker 2 Ohe yeah. Anyways, other things that I did aside from being in the hospital and all that is actually I didn't do very much, but my some of my friends in the community did a lot of like yoga classes. There's pretty cheap gym that the people went to as well. People went out to the mountains that's kind of near Ashby to ski and all that. There's a lot of recreational activities. There's bars to drink at. There's good food in Silver and Red Deer. There is a very questionable food place in Red Deer that adds sugar to their broth, which was a very concerning to me so I never went back. But there is other really good food places there. And obviously there's people who come and rotate into Sylvan Lake and Red Deer for whatever part. And so chatting up and meeting up with friends is also some of activities that I do. Speaker 1 Great to hear all of that. Yeah, when I was in Cold Lake, I had like a similar experience. There was a ski hill there. Went to the ski hill a lot. As soon as it opened, I was there with another student. So we actually joined the curling club and did like, pairs curling for the 8 weeks that we were there. And then this like, couple in their 70s just decided they were gonna like, adopt us and be our weekend activity planners and would like, take us throughout the city and like, teach us curling every week. So we had that. Otherwise, yeah, we also had like, farmers markets, all of that. How did you manage like loneliness and being away from your classmates? Speaker 2 I'm very much of A homebody, so it was not a brilliant impactful for me. I am very satisfied with sitting at home on the computer watching a movie or playing online games such as Titan and just kind of existing. And so I don't think loneliness was really ever much in my vocabulary. And so it didn't really impact me too much. And all my friends were quite busy with their day-to-day anyways and everyone was on different call shifts. And so I didn't see too many gatherings and if I ever were in the city for either some academic event or whatnot, I always try to meet up with my friends. And so that's one way to stay connected. And as I mentioned really early on in this podcast, my family is in Calgary. And so it makes a very short commute back to Calgary if I ever feeling like I'm missing some homemade food. And if I wanted any specific groceries, that's where I would go and get them. Aside from the superstore that is in Red Deer. Speaker 1 Fair enough. Yeah. I think again, it's like very person dependent and like knowing yourself and how well you tolerate like being away from others. And something I will say is even while you are in the city, like doing rotations in Edmonton, it's not like you have a lot of time to go and hang out with your friends who are on different rotations. I think me and my friends like who are on different rotations than me, we hang out like once a month, something like that. And that's something that we actually very like intentionally plan and have to like line up schedules for. There's not a whole lot of like casual last minute like hey, let's do this in clerkship anymore. We do get the benefit of like seeing people that were at the same site with while we're on the same rotation. So we do get like some human interaction, which is nice. I feel like I would find it a little lonely to be away from everyone for a year. But again, it's very like person dependent and like what works for you. Speaker 2 It's also really interesting that you mentioned all of that. It's because we are the longitudinal community. I become very friendly with all of my physicians that I'm working with. We'd like to chat about how their family is doing and how their dog is doing and all of that. And so, you know, in a day-to-day basis, I'm hanging out with these physicians both in outpatient and also in the hospitals. And so having those kind of almost, you know that that sense of commodity. Speaker 1 Is that the word camaraderie? Speaker 2 Camaraderie. There we go. That sense of camaraderie is quite important and also helps, I think, with the the loneliness that one might feel in rural community. Speaker 1 That is true. Like I've had preceptors invite me over in rural communities in Cold Lake. There was a preceptor whom I helped build his new house. I'm going to go visit his new house a couple of weeks from now. And I'm very excited to see the one panel that I helped build on that house. Yeah, I think, yeah, You do get a chance to really connect with the members of the community as we near the end of the episode. What's some advice you have for somebody who's just starting their third year of medicine like before they go on to the wards? Speaker 2 I think the, the advice that I would give to incoming clerks is that now there's a lot to learn because application of what you've learned in pre clerkship is going to be challenging and it's going to be a steep learning curve in terms of that regard. And you know, being gracious enough to forgive yourself if you make a mistake, if things aren't up to your expectations, it's gonna be very helpful. And not taking things with you at a personal level when you get bad feedback or negative feedback from preceptors or residents and being able to pick yourself back up and continue learning and continue improving your skill sets there as well. And also taking the opportunity to just learn and explore as much as you can and ask questions and be curious in terms of everything that you're on. And so I think that's something that I did, I would say quite well throughout my third and fourth years. I love asking questions. One of monthly anti docs I worked with was told me that I definitely get the reward for asking the most questions in a single day of ENT because I just kept on asking them questions about ENT even though I'm not going to that specialty. And so being that curious and asking the experts the important questions that you have about their expertise, it's going to help set you apart from other students and also help you learn a lot more about the specialty that you're on. Furthermore to that, I think also taking on the patients as your own and thinking about them as your own patient patients without kind of considering, oh, you know, I have a resident, I have a staff physician who will help me manage this. Take a stab at what you think the differential diagnosis is. Take a stab at what you think the next investigations is and what the management is. You'll likely be Ron starting off, but as you build up that confidence and getting a couple of them correct, you'll continue snowballing those kind of confidence growths and being able to become more and more confident in terms of your differentials and and being able to manage those patients. And so don't be afraid of making those mistakes because everyone makes them. It's a natural part of our learning and just taking that risk and doing it. Speaker 1 Wow, I feel like you gave a lot of advice. I don't even know if I really have any of my own, like advice to add to that. I think just being like open to learning and open to growth and realizing that you like, you don't know a lot. Like you've learned a lot in the classroom, but then it's a completely different ball game you're playing when you're out in the hospital. Like seeing how the stuff you learned is applied to practice. Like everyone has a very steep learning curve at the beginning. And I think just like taking some time and like showing some grace yourself and realizing that like everyone is in a similar boat to you and not to compare yourself. I had a bit of a more unique experience entering clerkship. I started, as I mentioned, on inpatient PEDs and I was placed on a small team and normally it's like 2 Med students per team. So my classmates who were also starting on inpatient PEDs would have like another classmate to kind of like learn along with them. I was paired with a fourth year who was there on elective. So like my classmates were there and we're like kind of stumbling through it together. Um, I was there with someone who not only knew what he was doing, but was there to impress. So he knew a lot. And I found myself comparing myself to him feeling like, wow, like I'm really underperforming here. Like this is not good at all. And I think just like if I could tell myself like back then to like take a step back and like acknowledge that like there, there's so much like room for growth within the year, I think that's what I would tell myself. Memorable Moments and Key Takeaways from Clerkship Let's end off with some fun. Let's end off with some stories. What What are some highlights from clerkship? Speaker 2 Yeah, I think ICC especially there I have a long list of things that I really proud of, things that bring back fond memories of patient care and also day-to-day interactions. Some of the things that I would highlight here is actually the longitude and nature of ICC. We able to see patients at their initial diagnosis, then offer some suggestions for investigations, treating the patients and then following up with those patients and community, you know, and, and the fact that, you know, Jessica alluded to this a little bit earlier is seeing those patients after you've discharged them from hospital and seeing them do and doing their daily activities is also something that is very memorable. I remember there's one patient whom both me and my preceptor were thinking that this is a bit of a dicey situation that they're in. They're quite sick. I don't think they're going to make it past this next week, but unexpectedly they made a full recovery and were discharged within a couple of weeks. And then I got to see them coming back, further follow up appointment in the community. We were able to stop in the hallways of the hospital, catch up a little bit and chitchat. They were very appreciative of the care that they received in the hospital. And you know, we can continue catching up if they ever ran into them again. So that's kind of the longitudinal nature of things. Another kind of positive example that I have is being able to see a patient initially and diagnose gender dysphoria of them, having them then go back to consider and think about it, consider the management options of all of that and then coming back for the treatment for generators for you. And I actually had the privilege of actually giving him his first testosterone injection. It was a very small step for me because I just pushed it in the syringe a little bit. But for him it was a great leap forward in terms of their his medical management and medical or personal identity, I should say. Yeah. So you know, these interactions of being able to follow up with patient longitudinally over a couple of months, over a couple, maybe even the entire year is something that's very rare in the large city because you are unable to do that. And just one other point would be following someone from their conception to actually getting pregnant, for example, and then seeing that delivery happen, following up the patient, seeing the NICU after them getting discharged and following up with them with them in community on their well baby check. It's something that can also happen within real community. I wasn't fortunate enough to see that, but one of my colleagues definitely was. Speaker 1 Yeah, I mean, I actually had a similar experience when I was doing like a longitudinal family Med placement. This was the Piano me program. So we did it during our reproductive medicine block and on my first day of like prenatal clinic for women, the first patient came in and she said like, oh, this is my first pregnancy. And I, and she was like, this is my first baby. And I said, oh, mine too. And then I had to clarify like by mine too, I mean, like you are actually the first like pregnant woman that I've met and assessed in a medical context. And then we started talking more and it eventually like went into like, when are you due? And then we realized she would probably be due around like the time when I would be ending my rotation. So like, I might get to see her deliver, I might not. Either way, it was like a very positive interaction. The weeks passed and she would come back in for follow up assessments. I would interact with her more. Sometimes she would come in after hours when I was on call with like just like concerns or new movements. Like you know how it is like first baby, like mom is very interested and wanting to know about every like new development that's going on and like unsure if this is like normal versus not. So I did get to see and interact with her quite a bit. And then on the last day of my rotation, she delivered. So yeah, it was very like special for both of us. It was also the first delivery I saw. Like I was just really unlucky. I was there for eight weeks on call every second day towards the end of it, like way more than I should have been. And just nobody was delivering on the days that I was on call until the very last day. And I got to catch this one baby. And it was like of the mom like the first like pregnancy assessment that I did. Speaker 2 Did they name the baby after you? Speaker 1 Didn't ask unfortunately. I think the baby was a male. Speaker 2 We could still get Jess or Jesse. Speaker 1 Fair enough. And I guess like other highlights that I had, there's kind of different categories of highlights. There's like longitudinal highlights like the one that I just described. There's also medical highlights. And I think Sam, as like a future internal resident, you'll be proud of me in that like I successfully identified sick versus not sick in a patient 3 * 3 times in a row in one week, identified septic shock in a patient. And for our listeners who don't know what that is, that is a medical emergency. And when, like in medicine, you talk about like, is somebody sick? Like we're really saying, like, are they gonna die? And I didn't actually know prior to that point if I would be able to at my stage in training, like identify, wow, you're really medical medically unwell. Like I need to go get help. And the fact that I was able to do it like 3 times in a row in one week was like very validating to me in terms of like, oh wow. Like I, I actually have developed like important skills and I feel like I've reached a milestone around this time I also started mapping out all the exits to the hospital. This was actually when I started doing that, but I do feel like that was a highlight for me. And then like there's the third category of highlights, which I would consider like procedural highlights. And being someone who wants surgery, like anytime I get asked to do something, it's very exciting for me, whether it's just like pulling the skin, retracting or like even doing a little bit of suturing, having people compliment my sutures. Like a, a small highlight for me was when the surgeon said your sutures look just like mine. I can't tell the difference. It was great. I would say the biggest highlight for me though, like people make fun of me for this all the time and like they don't understand why I like it so much. But it's like putting organs that are detached in bags and taking out the bags. I just find the whole thing, like, very satisfying. Yeah. And so, yeah, I think it's fair to say we've both had a lot of highlights. Let's end the episode on laugh for our listeners and talk about some of the low lights. Speaker 2 Yeah, my biggest slowly, I think from being in Red Deer was misidentifying A clinical assistant as a nurse. My learning from that was not everyone who sits on a stretcher outside of a patients room for a long period of time is a nurse. Sometimes they're there just to do charting. Speaker 1 Were they upset with you? Speaker 2 I don't know if they were naturally upset with me, but we chatted a little bit afterwards and we laughed about things and I think we're on good terms now. So I think the things ended up being OK, but it was quite embarrassing that first statements missing in finding them and then having to work with them the next week, That was definitely something. Speaker 1 Fair enough. I mean, I feel like it can happen to anyone. Like I've definitely misidentified a couple of people, like just from being in the clinic. Fortunately, I've misidentified them the other way. Like I misidentified the charge nurse as the anesthetist and she was actually really honored. Like we became like really good friends. She became like a motherly figure to me. It was great. And I also like misidentified a doctor as a resident once and like she was actually flattered. She was like oh wow, like this means I look young. She was also sitting in the resident lounge so I feel like it was a fair assumption for me to make. But I mean, like it can happen to anyone. I would say a low light for me is like learning that like not all surgical glue is same. So I don't know if you've had this experience while you're on your real rotations in terms of like varying levels of supervision, especially in the emerge. But a lot of the time if there was anything procedural in the emerge, I was just told to go and do it. And a lot of my classmates were told similar. So some of my classmates would like go to the bathroom and like watch YouTube videos on like how to do these procedures that like they've never done before. For me, it was never like that extreme. Like I had some practice in suturing before I was told to go in suture. But in this specific case, like I don't really know what was happening in Cold Lake that day, but it was 7:30 in the morning and three people got stabbed simultaneously. One of them was like very unwell. So all of the doctors were with him. And then I was basically put in charge of like dealing with the other two patients who had like more minor scrapes. And one of the things I had to do was like glue together this cut wound that a patient had on their, like, on their eyelid. And like the doctor looked at it and said, oh, you can just do it with glue. Here's the glue. And I think this was like week six or seven of eight for me at that point. And I'd been in the operating room a lot and seen surgical glue before and had an idea of how to operate surgical glue. This was not surgical glue. This was emergency room glue. This glue, like, came out a lot more forcefully than the surgical glue did when I applied the same amount of pressure. So like I pushed out the glue and then it just all kind of exploded out and like went down this patient's eye. And then I didn't really know what to do. I was like, keep your eye closed and then tried to like wash it out. And there was a bit where the patient like couldn't open her eye because I had like super glued her eye shut effectively. So I guess I've learned like a few things from the experience. Firstly, not all glue is same. Secondly, if a patient like has a wound, that's why you drape. It's not only to keep things clean, it's to keep surrounding structures safe. And yeah. Speaker 2 Was there a reason why you chose to glue instead of suture? Speaker 1 Because that's what the ER doctor told me to. Speaker 2 OK I would have just sutured cause I'm more comfortable doing that than gluing. Speaker 1 Also because I didn't know where the suturing stuff was and I knew where the glue was because the ER doctor gave me glue. Speaker 2 So matter of convenience. So kids, if you're not comfortable with something, speak up and someone will show you how to do. Speaker 1 So I was comfortable. I was just very confidently wrong. Like it's if there was like ever an issue where I wasn't confident, like I definitely would have like gone to someone and asked how to do this. I think this just went so badly because I was confident I was just confidently wrong. Speaker 2 Well, this is what they call the Dunning Kruger effect is that you feel like you're an expert in something, but you're really not. Speaker 1 Yeah, yeah, that's actually a good way to end off the episode. That's how you'll feel in 3rd and 4th year medical school. You'll think you know a little bit about a topic, and then as you do the rotation, you'll realize you don't know very much at all. And that's OK. Everyone feels like that. Speaker 2 That is very true. Everyone has a bit of imposter syndrome going in and everyone will leave with more imposter syndrome than they came in with and just a natural part of clerkship. And I don't know if we ever outgrow that even in residency in attending Hood either. Speaker 1 This was really not positive end to the episode Sam. Speaker 2 But everyone will do great, trust the process and it will workout in the best way that it can. Speaker 1 Let's turn this episode around shall we? Simple multiple choice question to end off. Which did you like better? Pre clerkships or your years in the classroom or clerkship? Your years on the wards. Speaker 2 100%, hands down, the clerkship years. I love being on the wards. I love interacting with patients and actually learning and doing the medicine that I've learned so much about. Speaker 1 I mean, I'm just going to say Ditto. Like I, I don't really have anything to expand to that answer. Like I am a kinesthetic learner and I feel like I just retain so much more learning by doing and it feels so much more rewarding working with a real patient. And I'll just leave our listeners with like a final example of something that happened to me. There's a condition, you can look it up. It's called rectal prolapse, where essentially your bum hole like falls out of the hole and falls outside of the body. It's really unpleasant. I learned through hands on experience that if that ever does so happen to you, you can put sugar on it, like common sugar that you have in your house and shove it back in and that's all you need to do. And I actually did go home that night and look at my slide deck from second year and like sure enough, it's in there. I didn't retain it until I saw it that day. And now that I have seen it and done it, I don't think I will ever forget. So yeah, definitely hands down clerkship. It's hard, but it's very rewarding. Speaker 2 Thank you for having me, Jessica, on this podcast. Speaker 1 Yes, we hope all of our listeners enjoyed. Thank you for coming, Sam. Speaker 2 Thank you.