High or low "Fund of knowledge" in clerkship evaluation?

[sozme]

This question is especially for residents/attendings/PDs involved in grading students... or students who know the specific reason they received a specific grade for this segment.

We all know that most evaluations have a section specifically for Knowledgebase or Fund of Knowledge. My question is simple: what would cause you to give someone a high or low mark under this category?

I.e. is it whether they get your pimp questions right most of the time? Whether they ask good questions? Whether they generally know what their role is in terms of their daily duties? Their H&P technique?

I've heard stories of students getting low marks for asking questions (the student thought by asking lots of question it would show interest). Also heard of students who never answer any pimp Qs right but still get perfect score here.

Just looking for some opinions.

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[cabinbuilder]

For me I don't mind when students ask questions but I like the discussion to be after the patient is seen. It can make the patient question the doctor's knowledge if you question procedure or medication choice in front the patient. Medicine doesn't always follow "the guidelines" and sometimes you have to tweak what you do that's not necessarily "standard". Patient's don't need to know that. You want the patient to have comfort and confidence in your care of them.

 

[Ismet]

I think it just depends on the individual grading you, their experience, and their expectations. I had a senior resident who said if a med student can answer more than 50% of her questions correctly, then she considers that a good fund of knowledge. But she was the only person who actually laid out her "rubric." Then I had an attending who is known for pimping and I felt like I was failing because I was getting all these "read my mind" questions wrong, but in my feedback at the end he said I had a solid fund of knowledge. I'm just as confused as you are about where this comes from.

As for asking too many questions, if it starts to hamper on your resident or attending's ability to get things done, it's obviously too much, and you could very likely get dinged for it. I think you also need a good balance between researching stuff yourself and asking questions. Like for surgery, you need to read up about the procedure the day before so you know what's going to happen, know the anatomy, know the basic steps of the procedure, etc because if you ask a question each step of the way, they're more likely to get exasperated with you. Also if you're asking a ton of questions that you are expected to know the answer to, that will negatively reflect on your fund of knowledge.

 

[cbrons]

Lol I think a good rule is to never ask any question that you can very easily find in a simple google search/access medicine/uptodate search. The best questions are more along the lines of technique or reasoning for certain approach in special situations, at least this is what I have found so far in my very limited time on the wards.

 

[Kaustikos]

Lol I think a good rule is to never ask any question that you can very easily find in a simple google search/access medicine/uptodate search. The best questions are more along the lines of technique or reasoning for certain approach in special situations, at least this is what I have found so far in my very limited time on the wards.

I'd just rather not ask questions period. Most times they say look it up... or, god forbid, tell you to shut up and not ask questions (isolated incident, I hope considering I've only had it to me and not heard it from anyone).

Evaluations; I don't really get issues with fund of knowledge. Residents understand the stress/level of business and bull**** we're dealing with and how pertinent good evals are for grades... so short of not answering ever, or seeming to be argumentative about residents telling you you're wrong, I don't think it matters much. But there's also residents who just don't like your personality and use that against you. So, don't argue, try to answer and seem interested and be okay with the personality thing. It happens.

 

[ketosisevangelist]

I've only asked how I'm doing in the rotation at the end of the week before the second half of my rotation. It's as this point I ask if there is anything that needs improvement. Give a hug goodbye. Never ask what my grade is.

 

[Kaustikos]

I've only asked how I'm doing in the rotation at the end of the week before the second half of my rotation. It's as this point I ask if there is anything that needs improvement. Give a hug goodbye. Never ask what my grade is.

People forget that or don't think of the value of it. I always ask for 5 minutes to sit down and talk with my residents/attendings about what I need to improve on. Sure, they have to write this down on paper/put it on computer, but I'd rather they tell me personally so I can work on it.
Spoiler alert; no one's ever called me unprofessional.

 

[22031 Alum]

If a student asks a ton of questions at inopportune times, I'm much more likely to ding them for poor situational awareness than poor fund of knowledge. I reserve fund of knowledge criticisms for students who clearly aren't doing any reading and have trouble answering basic student-level questions.

 

[cbrons]

If a student asks a ton of questions at inopportune times, I'm much more likely to ding them for poor situational awareness than poor fund of knowledge. I reserve fund of knowledge criticisms for students who clearly aren't doing any reading and have trouble answering basic student-level questions.

What would count as a "student-level" question?

 

[22031 Alum]

What would count as a "student-level" question?

On L&D, it'd be something like "What is the second stage of labor?" In the OR, things like blood supply and anatomic relationships. Things you'd find in Blueprints or similar books.

 

[operaman]

Any question where the answer can be found in a student review book like Step Up or MTB would be fair game. There are some common esoteric pimp questions that always get asked which may also fall under this category (ie. scorpion stings and pancreatitis). Any question that gets at underlying mechanisms and/or pathophys would definitely be student level.

Definitely agree that any question you can google and get the answer on the first page is not a good question to ask. Asking "what's that?" in the OR is probably not going to go over well unless it's a really strange variant (ie. I asked this once about a blood vessel I couldn't identify and as the dissection continued it turned out to be one the tumor had created to feed itself).

I'm not sure that pimp questions are how fund of knowledge is assessed though. More than anything, I think it's our presentations and how we participate in team discussions that shows how much we do or don't know. A number of faculty don't even ask pimp questions and sometimes ask things they would never expect students to know, but in general they all hear presentations or engage students in discussion at some point. In general, you can't really fake it and it's quite obvious who does and doesn't know what they're talking about.

One little tip I've found when asking questions: preface your questions with BRIEF snippets that show you've been reading. Rather than just "why are we starting X drug," try something like, "As I was reading I came across the ABCD trial which found drug Y showed benefit over X in a similar population; is there are reason we're starting drug X instead?" Of course that means you actually do have to read. No way around that.

 

[22031 Alum]

One little tip I've found when asking questions: preface your questions with BRIEF snippets that show you've been reading. Rather than just "why are we starting X drug," try something like, "As I was reading I came across the ABCD trial which found drug Y showed benefit over X in a similar population; is there are reason we're starting drug X instead?" Of course that means you actually do have to read. No way around that.

If you're going to do this, make sure the answer isn't "The patient is allergic to Y," "The patient has been treated with Y for six months without success," or something else that you should already know about a patient you have been following. It does not impress me when students have clearly been reading journal articles instead of their patients' charts.

 

[Kaustikos]

If you're going to do this, make sure the answer isn't "The patient is allergic to Y," "The patient has been treated with Y for six months without success," or something else that you should already know about a patient you have been following. It does not impress me when students have clearly been reading journal articles instead of their patients' charts.

I read in this journal article that pregnant women get no benefit from Zofran, so why are we giving it to her? <- Best thing I've heard in med school.

 

[operaman]

Yeah, you gotta use a little bit of common sense. Unfortunately, that's not always a given with some!

 

[ketosisevangelist]

People forget that or don't think of the value of it. I always ask for 5 minutes to sit down and talk with my residents/attendings about what I need to improve on. Sure, they have to write this down on paper/put it on computer, but I'd rather they tell me personally so I can work on it.
Spoiler alert; no one's ever called me unprofessional.

Give a hug goodbye at the end of the rotation.

 

[giantswing]

Give a hug goodbye at the end of the rotation.

Don't hug people good bye.

 

[evilbooyaa]

Give a hug goodbye at the end of the rotation.

Wtf? I would not recommend this. Maybe if you're a girl? I've seen girl medical students hug female residents that they were friendly with at the end of a rotation. If you're a guy - Firm (but non-excessive) handshake and "thanks for everything in these last x weeks".

 

[ketosisevangelist]

lol. Sure.

 

[cabinbuilder]

I read in this journal article that pregnant women get no benefit from Zofran, so why are we giving it to her? <- Best thing I've heard in med school.

No to mention all the ads on TV right now on how Zofran can cause birth defects and to call to see if you can sue.

 

[Psai]

Wtf? I would not recommend this. Maybe if you're a girl? I've seen girl medical students hug female residents that they were friendly with at the end of a rotation. If you're a guy - Firm (but non-excessive) handshake and "thanks for everything in these last x weeks".

i hugged two residents that i really liked and got along very well with but nothing besides that

 

[space3223]

My hospital has a SUPER malignant gen surg residency (former PD was asked to step down because his social skills and personal hygiene were/are so bad that it was preventing the program from attracting good residents - he is still at the hospital at a senior attending). I was told by my main surgery attending that they have been "warned" not to treat us the same way they treat the residents so they mostly ignore us. I only ever got asked three questions, all of which literally were someone pointing into an open abdominal cavity and asking "what's that?" Of course I wasn't in the surgical field (hands on the patient's legs for at least half of the 8-9 hour Whipple). I couldn't see anything so my random guess was always wrong but no one cared. The one thing that DID work well was asking the main surgeon I worked with (who did at least one Whipple per week) about a question about pylorus-sparing vs non-sparing surgery (if I remember the issue correctly). Mainly I knew from my limited reading that there is not a clear concensus yet (maybe now?) so I knew there was no "right" answer and that he would probably want to tell me what the "right" answer was, and he did, for about 10 min (barely spoke to any of us for the entire month before I asked that question, but again, super malignant program no on one was eager to talk much...)

I had another attending ask me to look up why some COPD patients are not hypercarbic ever (I had a patient like this, end-stage COPD, ABGs ALWAYS normal and O2 sat always at least 92% even when he would have episodes of severe dyspnea). I could not find an answer, only one paper from 1984 that found that it seemed to run in families so is prob genetic. Looking something super obscure like that up and asking the attending about it is prob your best bet (and knowing the basic regular pathophysiology as well...) and may help get a major pimp off your back if needed...

Good luck!

 

[awared2]

Wtf? I would not recommend this. Maybe if you're a girl? I've seen girl medical students hug female residents that they were friendly with at the end of a rotation. If you're a guy - Firm (but non-excessive) handshake and "thanks for everything in these last x weeks".

I hugged my rural rotation attending goodbye. She also got me a goodbye cake earlier that day to share with the office. Probably situational

 

[Psai]

I hugged my rural rotation attending goodbye. She also got me a goodbye cake earlier that day to share with the office. Probably situational

damn nice

 

[awared2]

damn nice

Well I did get them dunkin donuts donuts during the week too. Symbiotic relationship

 

[DrShazam]

I think it's 50% A&P, especially when presenting a new patient you've just seen in the ER, 40% pimping (mostly because this shows your ability to reason and think critically on the spot), and 10% personality and approach to asking questions (in general, management questions are the best to ask because there are nuisances often not covered in books or even uptodate but students who ask questions to show off their knowledge or simply because they want to seem interested drive me nuts).

 

[caffeinemia]

In the OR, let me at least say that any question about the patient, the basics of the operation, or the indication for surgery shows a lack of fund of knowledge/preparation. For most students, they see maybe 1-2 cases a day. This involves reading 1 H&P, maybe 1 radiology/pathology report, and reviewing the anatomy and steps of the case.

For example, in a mastectomy, if you ask an attending what the borders of the breast are, it would not be impressive. The attending should be asking you that, because you should know that common piece of knowledge. However, if you ask... say this SLNBx comes back positive and you do an axillary lymph node dissection and it comes back with 2 more nodes positive, would you still irradiate? Then I'd be impressed. Cuz that shows you read and know that there is controversy over the benefit of adjuvant XRT for 1-3 positive nodes + mastectomy.

Subtle differences in the way you ask questions -- those asking for more knowledge and those demonstrating sufficient knowledge to start thinking about the next step in decision making as a physician...

 

[Tired]

...

 

[colbgw02]

My caveman brain vaguely remembers the borders of the axilla being important for LN dissection WRT mastectomy. Guessing that's what was intended, or at least I'm trying to provide an out.

 

[notbobtrustme]

One little tip I've found when asking questions: preface your questions with BRIEF snippets that show you've been reading. Rather than just "why are we starting X drug," try something like, "As I was reading I came across the ABCD trial which found drug Y showed benefit over X in a similar population; is there are reason we're starting drug X instead?" Of course that means you actually do have to read. No way around that.

I've asked this question a few times and nearly every time the answer has nothing to do with actual medicine. It's more like "drug isn't covered by his/her insurance" or "too much paperwork to fill out, so I just use drug X" or "it's not on the hospital formulary" or something to that effect.

 

[Psai]

In the OR, let me at least say that any question about the patient, the basics of the operation, or the indication for surgery shows a lack of fund of knowledge/preparation. For most students, they see maybe 1-2 cases a day. This involves reading 1 H&P, maybe 1 radiology/pathology report, and reviewing the anatomy and steps of the case.

For example, in a mastectomy, if you ask an attending what the borders of the breast are, it would not be impressive. The attending should be asking you that, because you should know that common piece of knowledge. However, if you ask... say this SLNBx comes back positive and you do an axillary lymph node dissection and it comes back with 2 more nodes positive, would you still irradiate? Then I'd be impressed. Cuz that shows you read and know that there is controversy over the benefit of adjuvant XRT for 1-3 positive nodes + mastectomy.

Subtle differences in the way you ask questions -- those asking for more knowledge and those demonstrating sufficient knowledge to start thinking about the next step in decision making as a physician...

i don't get to see the surgery schedule until that morning. for some reason students are not given access to the surgery schedule or the imaging program that has most of the relevant imaging. so every day, we go in and then round/run the list until surgery starts. usually i'll have maybe 10 minutes to look at things and that's if i even have access to a computer which are usually taken up by residents or nurses. not complaining or trying to excuse anything though

 

[Kaustikos]

i don't get to see the surgery schedule until that morning. for some reason students are not given access to the surgery schedule or the imaging program that has most of the relevant imaging. so every day, we go in and then round/run the list until surgery starts. usually i'll have maybe 10 minutes to look at things and that's if i even have access to a computer which are usually taken up by residents or nurses. not complaining or trying to excuse anything though

Yeah,
Your program is backwards. I don't understand how its helpful to be restrictive in giving you access to patient info, schedule and imaging.
I would consider lying and just saying you're a resident so they don't treat you like they do right now: dingus

 

[notbobtrustme]

Yeah,
Your program is backwards. I don't understand how its helpful to be restrictive in giving you access to patient info, schedule and imaging.
I would consider lying and just saying you're a resident so they don't treat you like they do right now: dingus

that's risky. could end up as a professionalism knock (aka kiss of death) if someone finds out.

 

[Kaustikos]

that's risky. could end up as a professionalism knock (aka kiss of death) if someone finds out.

Hence saying consider versus doing. I don't endorse lying about who you are, but it seems sufficiently detrimental to students wherein action would be needed. I hated going to a hospital and having "restricted" access to patient information such as imaging/schedule/etc. The OR's that don't let students have access to scheduling, the staff were nice enough to at least give us a copy of the schedule the day before if we asked. Reminds me of the VA... do you work only at the VA?

 

[caffeinemia]

i don't get to see the surgery schedule until that morning. for some reason students are not given access to the surgery schedule or the imaging program that has most of the relevant imaging. so every day, we go in and then round/run the list until surgery starts. usually i'll have maybe 10 minutes to look at things and that's if i even have access to a computer which are usually taken up by residents or nurses. not complaining or trying to excuse anything though

Yeah that's rough. By fourth year I was pounding out 20 notes a morning for residents to "review and cosign." Made my fund of knowledge wayyyyy appreciated.

 

[Kaustikos]

Yeah that's rough. By fourth year I was pounding out 20 notes a morning for residents to "review and cosign." Made my fund of knowledge wayyyyy appreciated.

Honestly,
And it's probably just me, but I didn't mind the note writing because it forced me to learn about the patients. Which I didn't see the value in initially, but now I do. Now I'm not like deer in headlights when someone asks about a patient I "don't have" and can contribute to things. I guess I don't like being out if the loop. It's especially helpful when you do morning rounds on weekends and you're the only student there. If I know the patient, then I can pound a note out so much faster.
That's not to say I'm ecstatic about doing notes. It's just a nice way to study and review. And not have to page upper levels when you're the only one on the floor when the nurse asks you something.

 

[CherryRedDracul]

Give a hug goodbye at the end of the rotation.

Assess your relationship with your attending/resident/fellow/whomever, before you do that. If you two are close enough, then it can be appropriate.

The safer, more conservative approach is the handshake.

 

[Kaustikos]

Assess your relationship with your attending/resident/fellow/whomever, before you do that. If you two are close enough, then it can be appropriate.

The safer, more conservative approach is the handshake.

Yeah,
Agreed. Doing my vascular sub-specialty with my at-the-time not pseudo advisor was so awesome. Though, initially, there was a moment where he did a procedure and bro-fisted the nurse after finishing it and I was like "I wanna be a part of that.... " I waited, though, and refrained. I would hate to make the situation awkward. lol

 

[Psai]

Yeah,
Agreed. Doing my vascular sub-specialty with my at-the-time not pseudo advisor was so awesome. Though, initially, there was a moment where he did a procedure and bro-fisted the nurse after finishing it and I was like "I wanna be a part of that.... " I waited, though, and refrained. I would hate to make the situation awkward. lol

well at least you don't sit there in the OR as the attendings tell the residents hey that was a long case let's go get something to eat and totally ignore you because you're a medical student

 

[Mass Effect]

Don't hug people good bye.

Unless it's psych. We like hugs.

caffeinemia[/SIZE]]However, if you ask... say this SLNBx comes back positive and you do an axillary lymph node dissection and it comes back with 2 more nodes positive, would you still irradiate? Then I'd be impressed. Cuz that shows you read and know that there is controversy over the benefit of adjuvant XRT for 1-3 positive nodes + mastectomy.

It shows me that someone had a boring weekend of staying indoors trying to look for something to ask on Monday morning to be praised.

When I evaluate a student, I always remember that they're 3rd years and they're here to learn, not to stroke my ego by proving to me that they give a damn about ongoing research about whether or not some drug in an unrelated field might help people with face-picking anxiety as documented in some obscure journal that they'd never read on their own. Seriously, you'll never win with attendings/residents who are expecting that kind of thing. You're paying to learn and you're there to learn. Granted, we do expect you to do some of the work yourself, but I don't expect 3rd years to know anything beyond what's expected on Step 2. You'll get out of it what you put in. I think there was only one person who was truly not interested in learning (and I mentioned something on his eval), but everyone else has been great.

 

[JustPlainBill]

I'm more interested in seeing how a student thinks -- for example -- had one bright eyed/bushy-tailed UTSW MS3 as a student one time -- had them go see the patient first as I was finishing up paperwork -- student came back and presented -- conclusion was CHF exac -- but the PE wasn't matching up which became a teachable moment -- I correlated the PE findings reported and explained that they had given me no exam findings to support their diagnosis -- we then walked through the physiology of CHF and how it causes certain PE findings -- you could see the student deflate which is what they needed as they had come off as a little overconfident/cocky -- but they took correction well. I didn't slam them on their review for fund of knowledge -- why? Heck, I don't expect interns to know jack -- as a med student I expect you to have a rudimentary knowledge of the big areas of pathology/physiology in some sort of dysmorphic mass in your brain housing group and maybe some treatment options -- As an attending it's my job to train/guide you as to how to massage that dysmorphic mass into a workable "fund of knowledge" and then try to make sure you get the thought process down as that will make you able to evaluate and apply new knowledge correctly or old knowledge to new situations -- Not to beat you up for a "lack of knowledge" -- I've never understood how some residency programs will put an intern on probation for lack of clinical judgement -- they're interns, by definition they lack clinical judgement.

 

[Mass Effect]

I'm more interested in seeing how a student thinks -- for example -- had one bright eyed/bushy-tailed UTSW MS3 as a student one time -- had them go see the patient first as I was finishing up paperwork -- student came back and presented -- conclusion was CHF exac -- but the PE wasn't matching up which became a teachable moment -- I correlated the PE findings reported and explained that they had given me no exam findings to support their diagnosis -- we then walked through the physiology of CHF and how it causes certain PE findings -- you could see the student deflate which is what they needed as they had come off as a little overconfident/cocky -- but they took correction well. I didn't slam them on their review for fund of knowledge -- why? Heck, I don't expect interns to know jack -- as a med student I expect you to have a rudimentary knowledge of the big areas of pathology/physiology in some sort of dysmorphic mass in your brain housing group and maybe some treatment options -- As an attending it's my job to train/guide you as to how to massage that dysmorphic mass into a workable "fund of knowledge" and then try to make sure you get the thought process down as that will make you able to evaluate and apply new knowledge correctly or old knowledge to new situations -- Not to beat you up for a "lack of knowledge" -- I've never understood how some residency programs will put an intern on probation for lack of clinical judgement -- they're interns, by definition they lack clinical judgement.

Probably the most reasonable post in this whole thread.

 

[jonb12997]

Fund of knowledge in third year is tricky. Not specifically FOK, but I'm looking for your ability to synthesize the data presented by a patient or case and tell me what you think is going on based on your knowledge at that point. You might be completely wrong, but I want to see you think it through, tell me why you think that by backing it up with your knowledge base, and we'll talk about it. Then when asked what you want to do, you might again be wrong, but let's talk about why.
the other issue is how do you take information from one patient encounter and apply it to the next patient. Example, if we have a severe asthma patient that we do steroids mag continuous albuterol and send to picu, but the next day we have a patient who has less severe exacerbation, can you think about what we did yesterday and apply it to today's patient and how you would do things differently or even the same for this patient. Every patient can teach you something!

 

[Kaustikos]

well at least you don't sit there in the OR as the attendings tell the residents hey that was a long case let's go get something to eat and totally ignore you because you're a medical student

THAT would be horrible. But I'll say that I honestly find not being around them all the time a nice vacation.