Advice I wish I was given at the beginning of clerkships (koas)
Clerkships (”koas”) are over and I’ve walked out of it a fair distance to be able to turn around and reflect on the whole two years.
I went into koas with very little knowledge of it. During the theory years (”S1 years”), we got very little exposure to life in the hospital. We did get some brief glimpses thanks to field trips to puskesmas, etc. but these don’t really give you a full sense of what it feels like being in koas.
Many fellow medical students are hereditary doctors where they have pre-existing knowledge in the form of having heard anecdotes from parents and older siblings who are doctors during their whole lives up until now. Many students knew they were going to be doctors from a young age and had been preparing mentally with a long-term low-dose intake of medical and hospital knowledge for years. Many are Jogja citizens who had been in and out of these very same hospitals visiting their sick relatives, inadvertently observing the ins and outs and workings of the hospitals here.
Others had been involved in certain activities such as research, events, etc. during theory years that brought them into contact with clinical doctors, nurses, patients, and the hospital.
I was not among these. I come from a family where scarcely anybody is in medicine. Also I’m a foreigner so I have no reason to go to the hospital unless I’m sick myself (and I’m a pretty healthy guy - bar an appendectomy and otitis media infection). I was friends with lots of seniors. But I was friends with them for the sake of friendship and not for leeching off of them to progress my education/career. Whenever I felt like I was asking too much, I stopped myself because I felt awkward. They did talk about koas life among each other, but the conversation only made sense to those already in koas. I was often like a blind man at a tennis game: hearing the conversation, turning my head from left to right, but not understanding what’s going on. I was also dating a senior who was in koas when I was still in my theory years. But she was the type to almost never discuss her koas life with me other than what was absolutely necessary such as what time she’ll be done that day. Perhaps she underestimated my ability to understand just because I was her junior. She rarely shared with me her daily koas triumphs and trials. We rarely discussed medicine, although we both would have benefited from doing so. Lastly, my final year research paper in the theory years did not require me to go to the hospital. And I was never in any committees, groups, events, or such that required me to go to the hospital. To cut it short, I had basically zero knowledge going into koas.
Two years ago, just before kaos started, we got a series of talks from doctors and seniors. Their advice was always vague: “make the best of it. don’t worry. don’t be scared to ask. don’t forget to have fun.” Maybe it’s a bit helpful, but I won’t waste your time being that vague. I want to tell you very specifically things I wish I had been told during these talks:
1. Always eat. Food is energy and koas is going to drain it. You will often be in situations where you feel stuck: you aren’t doing anything useful but you can’t go home, you can’t leave, and you can’t eat. Get rid of this mentality. You can always eat and you must not feel too ashamed to do so. Once I realized the importance of eating, I would often excuse myself to go to the toilet and then sneak into the cafeteria to fill my belly. I would often bring snacks in my pockets and backpack. I would always, always, always have bottles of water with me. As long as you’re avoiding hunger, eating healthy, and staying hydrated, you will be energized and motivated in koas.
2. Sleep. Don’t be scared to take shameless naps everywhere. You can sleep during lectures, presentations, etc. easily. You can sleep while waiting for doctors. Even a 15 minute nap can freshen you up. I know some expert sleepers who sleep so much during koas that they simply don’t sleep much outside of it: having social lives, playing games, studying, etc. I got a blindfold (is that what you call it?) and noise-canceling earphones to help me sleep.
3. Don’t fight with koas mates trying to get easier cases, etc. It happens all the time: there’ll be a situation where you have to split work: cases, patients, topics, whatever. There are always prejudices about which topics or cases are “easier” and which are harder. Often, these assumptions are wrong. A simple sounding disease may have a lot of literature about it, requiring more reading, and it may be so well known that the instructor will expect deeper research from you when presenting. Be smart and play the compassionate card: tell them you’ll let them have the easy cases “this time” (but do it every time). You will avoid an uncomfortable confrontation and they may return the favor later by being nice to you in other ways. Also by taking on challenging sounding (but not actually challenging) or obscure cases, you’ll be educating yourself on something potentially new and interesting, you’ll gain the admiration of the instructors and peers, and you’ll probably get away with making mistakes.
4. Check the nurse station for vitals. You don’t need to spend two years of koas taking vitals over and over. That’s stupid. Instead of wasting time on vitals, practice with your stethoscope. Patients don’t know if that’s part of vitals or not, and you can never get enough auscultation practice. You may even find a murmur and impress your instructors.Â
5. You’ll often be working with and around residents (variably depending on which hospital and which department). Most residents respond better to koas who have “street smarts” and enough basic knowledge to be confident. They also respond well to koas who can help lighten their load. Don’t waste their time by asking them basic questions you can get the answers to online. Most residents don’t care how respectfully you speak, how low you duck your neck when greeting people, how soft your voice is, how many buttons on your white coat are fastened, how you refuse to rest or eat, or how many assignments and books you carry around. You don’t even have to be super intelligent to win their respect. Remember, nobody knows your GPA. If you do a bit of homework before starting a new koas department, you can look fairly knowledgeable. It isn’t hard and takes just a day’s investment to go over all the competencies/diseases listed in the koas book. After this, you can get the confidence to actually be useful. I remember in the Surgery and Pediatrics departments, the residents were often relieved that I had followed up our patients more thoroughly and was able to help the residents answer questions during rounds. As long as you’re being responsible, the residents will be happy to give you permission to “go eat”, which often just means to go home and nap for an hour, and then socialize with friends for another two hours over dinner. Don’t be scared to simply ask the residents if you can leave. As long as you aren’t sacrificing your duties and appear responsible, the residents will be willing to take any one of your countless fake excuses: work on group assignments, go to KKN meetings, etc. etc.Â
6. Dare to have basketball-sized gonads. The midwife asked me, “have you delivered a baby yourself before?”  “Of course! Often!”, I lied blatantly, telling her to relax and let me do this in peace myself. In reality, I had only ever seen midwives and doctors deliver babies. I remember I had tried really hard to capture every movement and every step in my mind so I can do it with confidence when the time came. Another time, I simply asked to assist in a surgery and the doctor got a bit taken aback at my confidence, but then agreed. It was great sticking my hands into an abdomen for once (something which is considered a big no-no for koas for some reason).Â
7. At every new hospital you go to, invest a bit of time doing a survey in and around the hospital for: best food, best toilets, and best showers. I have taken hot showers in unoccupied VIP rooms, taken glorious poops on brand new toilets on newly renovated floors, and eaten at clean little restos just a couple hundred meters from the hospital. When I started koas, GoFood wasn’t widely available but now it is. So, near the end of my koas, I extensively used GoFood to eat delicious food all the time. At one time, I used to have my maid pack cut fruit and snacks in tupperware for me to take daily.
8. Don’t take anything to heart. Always remember one thing: koas is temporary. It’s basically like a rapidly flipping magazine. The days go by like pages and old chapters don’t matter. So, don’t get into conflicts and if you do, forget them and move on immediately. Your main goal must always be to get through koas with harmony. It will be over before you know it. It will go fast because it is divided into departments and you will always move to a new department right when you’re getting comfortable. You will be going in and out of “luar kota” (rural hospitals) and all this will keep you busy enough to forget that time is passing. People’s opinions are just that: their opinions. You can choose to take something to learn from them, but don’t ever let people’s words cause you permanent injury (to your ego or confidence). You will make mistakes. You will be told off. But just laugh, apologize when appropriate, and keep going. At the same time, keep your opinions to yourself unless they benefit you somehow. Keep your ego in check. It isn’t worth picking fights with your groupmates, nurses, etc. These people are temporary and you won’t see them again after koas is over. But for now, you need them. You need them for shifts, and alerting and reminding you of assignments and meetings.
9. I learned the most and got the most out of the hospital in Klaten: the surgery department is overflowing with patients and I had an endless supply of interesting cases in the ward. The other place I learned a lot was the ER in Klaten. It is understaffed and brimming with patients. I was very often allowed a great deal of autonomy just because the doctors and nurses were too busy with other patients. The places I learned the least were classrooms in Sardjito. Perhaps the material was useful but because it was in a classroom setting, the memories melted away. What stuck with me are memories of real patients that I saw, talked to, touched, and followed up from start to finish. I remember their diseases and remember studying about them as a result of meeting those patients. You will see an irrational distribution of trust in the hospital: in the OR (operating room), they don’t trust a koas to sit the right way on a toilet. However in the ER or during Obsgyn, I was often allowed to do minor surgery all by myself, install IV lines, etc. So, don’t waste your time in places where (thanks to stupid ingrained stereotypes) they don’t trust you. As much as I enjoyed watching surgeries in the OR, I got much more hands on experience in the ER, VK (birthing room), and even poly-clinic. Also, I shouldn’t have to tell you this, but you’re in koas to gain general physician competencies. So, as cool as the specialized stuff looks, focus on getting your GP competencies first.
10. Request to combine refkas, tutorials, mini-CX, etc. It isn’t always easy to find, schedule, wait for, and travel to these things. So, don’t worry about working a bit harder to finish two assignments for the same day. The time saved by combining them into the same meeting will easily outweigh any extra time you spent finishing your assignments quicker. One of the worst things that can happen in koas is you not finishing your refkas, tutorial, or mini-CX by the end of the department. So, of course, the earlier the better anyways.
11. Live closer to the hospital. This is a mistake I made: I chose to live too far from the hospital. Shortening your commute is going to benefit you on a daily basis. Even if you have to pay more and live in a smaller place, choose to be closer. I live right near RSA (hospital) so when I was assigned there, it was heaven. I could leave home 5 minutes before I had to be there and return home in the middle of the day, just for a quick shower or lunch or just to poop in peace. Sadly, being far from Sardjito means that my commute is 15-30 minutes. It isn’t near enough to go back to to wait for a doctor to become available.
12. Three white coats. I chose to get three with different materials. It was a great decision. When I knew I was going to be in a hot room all day, I wore the one with the lighter material (and I’d highly recommend this one, because I found myself wearing it more than the other two). Having three meant that I could laundry them lazily whenever I got the chance. I know some koas who only bought one and were forced to wear a dirty white coat because they had no chance to wash it.Â
13. Don’t bring textbooks. You won’t read them and they’re just going to weigh you down. My backpack was always filled with snacks, convenience items, and water. I never brought a textbook and even the ones at home, I never opened them. Instead, I got most of my knowledge from PubMed, Mims app, Patient.info, and of course my UptoDate.com membership. My backpack also served as a great pillow (thanks to the padded back) on many occasions.Â
14. Sketchers shoes. The ultimate best investment for koas. I bought these at the beginning of koas and used them throughout. They went through a lot as I wore them daily, and they’re still mostly okay. They’re super light, easy to wash and dry, easy to put on take off, well ventilated, and heaven for your feet. You will spend a lot of time standing and walking in koas, and sore feet will make your whole body ache. I used the official Sketchers ankle socks. Excellent investment.
15. Plan for the future. Keep an UKMPPD journal/file where you write down stuff from each department to help you for this exam at the end of koas. Think about your career in the future. Do you need to network with certain specialists so you can get research assistance work later or letters of recommendation? Do you want to take part in events and conferences so you can get experience and build your CV? Start a LinkedIn profile and start networking right off the bat from the beginning of koas. Don’t underestimate your peers: they may be koas or residents today but tomorrow (and by tomorrow I mean just a few years) they will be the leading doctors of Indonesia. They may even be your bosses or your boss’s bosses.
That’s all the time I have for now. (Got the UKMPPD coming soon and I need to study!) Good luck!