Source: Clerkship Info Night Handout 2010, Faculty of Medicine, University of Toronto.

So this week, the 2nd year medical students at UofT have a big decision to make.  We have to rank our clerkship rotation schedule preferences so that the UofT clerkship matching system can match us.  In case you are not familiar with the matching process, or the rotation schedules, let me break it down for you.

As you can see from the above picture, there are 6 rotation schedules, each one comprising of 2 blocks, a "Hard Block" and "Easy Block".  When I refer to the "Hard Block", I mean the block that consists of Surgery, Medicine, and Anesthesia/Otolaryngology/Emergency Medicine.  The Easy block is the one with Paediatrics, Family, Obstetrics and Gynecology, and Psychiatry.  So just so we're all clear, Rotation A B and C all have the Easy Block first and Hard Block second, with the individual rotations occurring in different orders.  Vice versa for rotations D, E, and F.

So part of our job by this Friday is to rank all of these various rotation schedules, but UofT is a bit more complicated than that.  Since there are SO many hospitals in Toronto that UofT is affiliated with, we also have to choose which hospitals we want to do these rotations at.  More precisely we have to choose the "Academy" that we want to be part of.  So yes here is some more background material.  At UofT there are 3 Academies, sort of like the "Houses" in Harry Potter, and each Academy is associated with one or more hospitals.  There is the Fitzgerald (Fitz) Academy, associated mainly with St. Michael's Hospital.  There is Peters-Boyd (PB), associated mainly with Women's College, Sunnybrook, and North York General Hospital.  And finally there is Wightman-Berris (WB), mainly associated with Mount Sinai, Toronto Western, Toronto general, and Princess Margaret Hospital.

Since there are 3 academies and 6 rotations, you realize quickly that there are yes 18 different combinations of rotation and academy that to rank. And yes UofT wants us to rank ALL 18, not just our top 6 or something.

So now that you understand how the rotation/academy system works, I'll move on to the decision making process.  The reason why this is such a big decision, is because a large portion of our CaRMS application (Canadian Residency Matching Service) to apply for the specialty of our choice, depends on how well we do in clerkship.  Our preceptors have to give us evaluations on each rotation, and furthermore, the reference letters we use for the residency matching service will be letters we get from the people we have impressed during clerkship. AND of course, us being medical students at UofT who want to score the best residency possible, we want to make sure that the rotation schedule AND academy we choose fit us the best.

So how DO people choose? Well let me go through some of the general strategies that people have used before.

a) Do the Hard Block in the winter, and Easy Block in the summer. Why? Well upper years have made it very clear that for things like Surgery and Medicine, you will NOT see your friends. When you join teams in those rotations, there is usually only 1 or 2 clerks on any given team, and with overnight call, and night time studying, you will have no social life. (Yes you have to study! There is a written exam at the end of many rotations! AND you gotta study so that when the doctor pimps you the next day about the patient you have been assigned to, you don't sound like a complete idiot!).  So since the Hard Block is, well, HARD, then do it in the winter, and do the Easy Block in the summer, when the sun is out and you can actually have a life.

Of course there is a CON to this rotation schedule.  In the coming September, we will all be tossed into the clerkship mix for the very first time and so as you can imagine, there will likely be a HUGE learning curve at the very beginning.  At the beginning you won't know the hospital routine, or the "unspoken" rules of etiquette amongst the doctor/resident/clerk hierarchy (e.g. one rule I learned in shadowing - if you are a clerk NEVER come back from a coffee break BEFORE the resident/fellow that is higher than you. It will make them look bad in front of the preceptor). Furthermore, your confidence and self-esteem will be crushed by the people around you as you finally realize how much you don't know.

So if you do the Hard Block first, then it's going to be REALLY hard! And if you want to gun for Internal Medicine, or Surgery or any of the other residencies in the Hard Block, you might not do as well if the Hard Block is first.  To be frank, this is an important reason, especially among keen people, to not do the Hard Block first because the really keen people tend to pursue careers in Surg/Medicine/ENT/Anesthesia or something related.  The Easy block has Family Med and Psych which are usually not as popular among the "really keen", and so doing them first, and possibly not doing as well in them, is not a huge issue.

b) So of course this leads into the next line of thinking, which is choose the Easy block first and the Hard block second.  Why is this good? Well it changes up the disadvantage I just mentioned. Now that the Hard Block is second, you have the whole Easy Block to get used to the clerkship system, and if you are a keener, you want to do well on the Hard Block so that will be a plus.

So why NOT do this? Well you will have no life in the summer. AND it may affect your "elective choices".  What I have not shown you in the picture at the beginning of this post is that everyone will have 12 weeks of electives in the September-December AFTER the core rotations (listed in the diagram) are completed.  So I, for example, will start clerkship in Sept. 2010, but will do my 12 weeks of electives from Sept-Dec. 2011.  What you have to now consider is that we have to apply to get electives as early as 9 months ahead.  If you want to do an elective outside UofT, like in UBC, then it is recommended to apply 1 YEAR in advance! That means I will need to apply for my Sept 2011 electives in Jan 2011!! But if I do the Hard Block second, which will occur in Summer 2011, then I will not have connected with any doctors, or will not know enough about Surgery or Medicine to choose a good elective. So if I was really keen on getting good electives in Surgery or Medicine, it might be better to have those in the first block! Oy the choices eh?

Of course there are many more reasons for choosing the Easy or Hard blocks first, but these are the general considerations that one must ponder. Now let's continue by adding another layer of complexity.

If you have not guessed yet, that layer of complexity is ACADEMIES.  As you may well be aware, NOT ALL ACADEMIES ARE EQUAL. One general trend that has been common year to year is that there will be many students who will NOT want to do their clerkship with PB, because their main hospital, Sunnybrook, is in mid-town Toronto (Near Highway 401 and Bayview).  Why is being at PB an issue? Well let me give you a real life example. You are a clerk. You just started your surgery rotation, and guess what? Surgery starts their morning rounds at 6am! ALSO guess what? the TTC subway system OPENS at 6am? AND Sunnybrook is NOT at a TTC station, but requires a bus ride FROM a TTC station. AND the shuttle service from Women's College to Sunnybrook does not start that early! So what does that mean? If you do not live beside Sunnybrook, and do not have a car, you are screwed. This is a problem for UofT med students since a majority of people live downtown. So as you guessed, many people rank PB as their last 6 choices, despite what rotation it is. One thing to note is that Surgery and Medicine for PB will always be at Sunnybrook.  Some of the other rotations would be at North York General, at Women's College, or in the community, but not Surgery and Medicine. That is why if you choose PB, PLAN on being there at 6am during your Surgery rotation.  (And 7:30 am for your Medicine rotation!).

What other considerations are there? Well many people like WB because you get the breadth of rotating through various different reputable hospitals, such as Toronto Western, Mount Sinai, and Toronto General Hospital. These hospitals are at the forefront of research for many different things, and you might get to see cool/out of this world medicine at work, not to mention meet the doctors behind them!  What about St. Michael's? Lots of people like St. Michael's because it serves an inner city population (a.k.a. there are poor people in its community, as well as rich people).  Also, the staff there have been rated, by many, as the friendliest and the best to learn from, compared to PB and WB. (I am highly biased since I am a Fitzie for preclerkship).

So now that you have a taste of the issues surrounding this clerkship matching scheme, how is the match done? And what are the results?  Well at the Clerkship Info Night we found out the following bits of information.  2 years ago, in the 2008 match, 29.9% got their 1st choice, 28.1% got their second choice, and nobody got lower than their 7th choice. In the 2009 match (last year), 25.9% got their 1st choice, 20.2% got their 2nd choice, and 18.9% got their 3rd choice, with nobody getting lower than their 8th choice (actually only one person got their 8th choice, and he submitted his ranking late apparently).  So what does this mean?  MOST people will get their 1st, 2nd or 3rd choice, and probably nobody will get lower than their 8th choice.

How is the ranking actually done? According to the mastermind behind the matching system, they take the least popular rotation+academy choice, and match that one first to the people who ranked it the highest.  Remember, each rotation+academy has a certain number of spots and ALL of them have to be filled.  So filling the least popular ones first makes sense. What that ALSO means is, if you put an unpopular one high enough on your ranking, you will most likely get it.  So for example, if in my top 6 choices, if I put one PB rotation there, even if the other ones are not PB, I probably have a high chance of getting that PB rotation, without consideration to my other choices?

So given all this information, you might be asking, so Jerome, what are YOU deciding? Well haha my brother just told me that maybe I should hold off on writing about what I chose and why, in case there are other people in my class reading this, and also so I have something else to blog about!  I will discuss what I chose after coming Friday, when the match is due, so watch out for  it!

I hope this gives insight into "clerkship" and if you have any questions about the match, or the different lines of thinking, please comment!