Immediately discouraged on rotations...

[PathNeuroIMorFM]

Finished first week on rotations in an easy going peds clinic setting. I thought I was coming in mentally, emotionally, and academically fairly prepared after a research year. I'm comfortably knowledgeable in my vaccine schedules, my dev milestones, common PE findings, and - at the risk of sounding cocky - families and kids got along fantastic with me. My clinical skills were a bit rusty, but I picked it up in a day or two. Showed up early and left late every day.

I worked mostly with the clerkship director. Tried to be genuine, relatable, funny, laugh at his jokes. I'm self aware enough to not give off gunner vibes or outshine others. Found PE and history findings no one else caught. Worked my ass off to impress him (and everyone else), since he's the one who determines my grade. So far he gave me a 3/5's, whereas the other residents+ the NP each gave me mostly 4s. I'm no charismatic casanova, but I get along well with everyone I meet. I just get the feeling he really disrespects or dislikes me.

When I get home, my UWorld scores are averaging like 50% for a variety of reasons. Sometimes it's a niche diagnosis I haven't learned yet, sometimes I get a bit "tilted" (as the cool kids say) and didn't read the question correctly. I know it's a learning tool and not an assessment tool, but after a tiring week, it's just insult to injury.

I'm reflecting on this week today and I'm just so sad and discouraged. How do I keep my chin up? How can I show up to clinic with an iota of hope that anything good will happen?

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[SpoiledMilk]

Let me guess. You would go into the exam room with either the residents or NPs where they observed your interactions with the patient, present to the attending outside the rom, and then go with the attending in the room and stand quietly as the attending talked the whole time. The attending does not observe your interactions with the patient at all. At least that's how my clerkships and rotations in outpatient peds went, and my evaluations reflected that.

If so, either constructively tell the clerkship director that this format sux (gently) and that they should be observing your interactions like the residents or NPs, or else get used to the 3/5s because outpatient Peds attendings were my worst evaluations because of the format I experienced above. If you're not going into peds, ace the exam, make the most of the remaining time, and move on.

 

[cj_cregg]

3/5 is a perfectly fine/average score and is not anything to worry about in and of itself. If you are concerned about this rating, sit down with the clerkship director and ask if he can give you feedback on what you're doing well and how you can improve. Maybe he has some legitimate reason for the score. But also, if there isn't anything specific he wants you to improve on, recognize that not everybody on your rotations is going to like you, and that is fine and won't have a significant impact on your life beyond the few weeks you're with them.

 

[PathNeuroIMorFM]

Let me guess. You would go into the exam room with either the residents or NPs where they observed your interactions with the patient, present to the attending outside the rom, and then go with the attending in the room and stand quietly as the attending talked the whole time. The attending does not observe your interactions with the patient at all. At least that's how my clerkships and rotations in outpatient peds went, and my evaluations reflected that.

If so, either constructively tell the clerkship director that this format sux (gently) and that they should be observing your interactions like the residents or NPs, or else get used to the 3/5s because outpatient Peds attendings were my worst evaluations because of the format I experienced above. If you're not going into peds, ace the exam, make the most of the remaining time, and move on.

No one is present in the room. I take the history/PE, maybe give some light advice ("your newborn should have vitamin D etc etc we will get you a prescription". Present my findings to either attending/resident. We both go back in and I stand in corner silently while they sometimes repeat some manueurs for no reason and give advice that I shouldn't give as a medical student.

@CaponeAl They don't force us to work with them. I opted to because it was easy at the moment and I knew they would grade me fairly. Not a major concern and I'll never see them again anyway.

I did ask the clerkship director what I can be doing at the end of the week and he just said "Just keep working on your history taking" before running out of the room for lunch. He's not the greatest from what I've heard from my M4 peers.

It's a very long story, but doing well on this rotations (and all rotations) is just important for me because I need to make up for some lackluster performance in preclinical. Bottom quartile of my class and need to break out.

 

[SpoiledMilk]

Yeah, that format sux big time because the attending is not observing your interactions with the patients. If you are not going into peds, it doesn't matter if your overall evaluation is a P. Just make the most of the remaining clerkship and move on. H or HP the other clerkships.

 

[cj_cregg]

Okay, so if other students are saying he's not great, sounds like it's a him problem and not a you problem. Not much you can do about it other than continue to try to do your best and learn whatever you can from the rotation, so not worth worrying over.

 

[Billiam95]

Some rules from observations from the tail end of MS3 - 1) time in the hospital has zero correlation to your evaluation. 2) 90% of your eval grade is dependent on sussing out who not to send an eval to.

3rd year is hard, lots of ups and downs, just got to put your head down and push through.

 

[Dantes]

Welcome to third year, where everything's made up but the points do matter.

If possible and you're able to pick sites/preceptors, figure out which ones are better or give good evals. Your situation is not uncommon unfortunately.

 

[Esmolol]

Welcome to the dungeons of MS3 hell…

 

[esob]

MS3 is highly subjective, though, as mentioned above, figuring out who to ask for evaluations is one thing you can do to tip the scales in your favor. Also, figuring out what is important to the people you work with can help tremendously. Some attendings want you to run the full gamut during the presentation. Some don't care about your style but want to know if you have a good differential. Others are simply trying to make it through the day, and anything you do to expedite the process gains you favor.

At the end of the day, remember that you are not alone; others are going through it with you. It helps to have a buddy who you can commiserate with.

 

[deleted1139416]

Obviously I don't know anything about you and everyone has their own journey, so please take what I am saying with a grain of salt. One important thing I have learned about rotations is to let go of the expectation that you will be perfect. Third year should be an opportunity to allow yourself to make (reasonable) mistakes and learn from them. Worrying too much about evals and scores will only get in the way of that.

 

[throwaway123342]

3/5 is a perfectly fine/average score and is not anything to worry about in and of itself. If you are concerned about this rating, sit down with the clerkship director and ask if he can give you feedback on what you're doing well and how you can improve. Maybe he has some legitimate reason for the score. But also, if there isn't anything specific he wants you to improve on, recognize that not everybody on your rotations is going to like you, and that is fine and won't have a significant impact on your life beyond the few weeks you're with them.

3/5s will make your app dead on arrival.

 

[cj_cregg]

3/5s will make your app dead on arrival.

Goodness. Depends on the school and residency/specialty I suppose, but that has not been my experience. First of all I have yet to see an MSPE from any of the dozens of schools I've seen that actually lists the individual ratings students were given, it's always been just the overall grade, histogram of grades for the whole class, and narrative comments from the evals. So OP has nothing to worry about if the bulk of his evals are 4/5 even if that were true. Second of all, at most schools 3/5 is by definition average/meets expectations so the bulk of students will be in that range. I'd imagine we'd have many more open residency slots by the end of the match if that made one's app dead on arrival.

 

[deleted1139416]

Goodness. Depends on the school and residency/specialty I suppose, but that has not been my experience. First of all I have yet to see an MSPE from any of the dozens of schools I've seen that actually lists the individual ratings students were given, it's always been just the overall grade, histogram of grades for the whole class, and narrative comments from the evals. So OP has nothing to worry about if the bulk of his evals are 4/5 even if that were true. Second of all, at most schools 3/5 is by definition average/meets expectations so the bulk of students will be in that range. I'd imagine we'd have many more open residency slots by the end of the match if that made one's app dead on arrival.

i think they were just being inappropriately sarcastic.

 

[When the Moon Forgot]

Some people just grade like that. 3/5 is theoretically where you should be at but everyone knows to avoid peeps who 3 bomb everyone.
Big part of third year, unfortunately, is to figure out who 5 bombs everyone (like me) versus who 3 bombs everyone.
Clerkships have almost nothing to do with clinical knowledge or skills. They're mostly about which evaluators you choose.

 

[RangerBob]

Some people just grade like that. 3/5 is theoretically where you should be at but everyone knows to avoid peeps who 3 bomb everyone.
Big part of third year, unfortunately, is to figure out who 5 bombs everyone (like me) versus who 3 bombs everyone.
Clerkships have almost nothing to do with clinical knowledge or skills. They're mostly about which evaluators you choose.

This pretty much sums of 3rd year.

On my OB rotation in particular, I was assigned to the busier (longer & busier days, more call) and harsher (attending/residents) academic location. We had less free time to study. We had less hands-on experience. Our ratings from residents/attendings were notably lower on average, and our Shelf scores were lower on average as well.

The students who rotated at one particular community hospital: no residents (more hands-on experience). Easy-going attednings who taught a lot, let the students do things, and sent them home early. No call. Lots of time to study.

The community hospital site students literally did less work, with less stress, and ended up with better subjective (evals) and objective (Shelf) scores.

 

[deleted1139416]

This pretty much sums of 3rd year.

On my OB rotation in particular, I was assigned to the busier (longer & busier days, more call) and harsher (attending/residents) academic location. We had less free time to study. We had less hands-on experience. Our ratings from residents/attendings were notably lower on average, and our Shelf scores were lower on average as well.

The students who rotated at one particular community hospital: no residents (more hands-on experience). Easy-going attednings who taught a lot, let the students do things, and sent them home early. No call. Lots of time to study.

The community hospital site students literally did less work, with less stress, and ended up with better subjective (evals) and objective (Shelf) scores.

I’ve always felt like I learned less on ward based academic rotations because attendings and residents were always too busy. At least for preceptor rotations my attendings had time to teach.

 

[PathNeuroIMorFM]

Small update:

Done with all of my time in clinic, but still waiting to take OSCE/Shelf. I've definitely taken the "time in clinic doesn't translate to learning" straight to heart. I can only learn about the same 3 bread and butter cases so many times.

I tried my best to pass on evals to the good ones and avoid the bad ones, but 50% of them were extremely hard to read. I am a little concerned that even when they smiled and said "good job today", their writing may not reflect that. Only time will tell.

Thank you all again for your advice. I'll update again when I get my grade back, which is entirely in the hands of my shelf score now. Wish me luck!

let go of the expectation that you will be perfect

And thank you for this. It's going to be a lot easier said than done, but I'm trying.

 

[thumbz]

Any chance it's your school's grading scheme?

I precept for.... 4 medical schools now. Which shall remain nameless, but:

School A - if I 4 bomb everyone (they don't go to 5?) I get an email asking me if I mis-read the eval or misunderstood the rubric. Strait 4's in their mind means the student is a better attending than I am. MS3's get 2's, maybe 3's, MS4's get 3's, maybe 4's.
School B/C/D - 5 bombs all the way unless you're profoundly annoying.

It's a crap shoot, but take comfort knowing as the guy who reviews applications for residency clinical grades mean jack **** to me, for the exact above reason. Your MSPE will give me your grade average relative to your peers which I look at, and then I read the comments you got thoroughly as that's where the beef's at. So don't worry even if you get strait 3's, as long as you don't get any harsh comments.

 

[PathNeuroIMorFM]

Any chance it's your school's grading scheme?

I precept for.... 4 medical schools now. Which shall remain nameless, but:

School A - if I 4 bomb everyone (they don't go to 5?) I get an email asking me if I mis-read the eval or misunderstood the rubric. Strait 4's in their mind means the student is a better attending than I am. MS3's get 2's, maybe 3's, MS4's get 3's, maybe 4's.
School B/C/D - 5 bombs all the way unless you're profoundly annoying.

It's a crap shoot, but take comfort knowing as the guy who reviews applications for residency clinical grades mean jack **** to me, for the exact above reason. Your MSPE will give me your grade average relative to your peers which I look at, and then I read the comments you got thoroughly as that's where the beef's at. So don't worry even if you get strait 3's, as long as you don't get any harsh comments.

According to the school, people tend to do similar across rotation sites. I'm taking that with a heaping load of salt.

They did step in last year after everyone honored one site, but didn't step in after only passing everyone at another.

That's good to hear, though. I would be incredibly surprised if I got any harsh words. More likely that I wasn't noticable enough to make a bad or glowing comment by anyone.

 

[Esmolol]

They did step in last year after everyone honored one site, but didn't step in after only passing everyone at another.

Sounds about right. That's also my experience with med school in general. "You're a student. You need to be miserable and you don't deserve good things. If good things happen to you - we will take them away."

 

[annoyedpsychiatrist]

As a preceptor here are the 3 things I look for above anything else:

1. show up
2. do your best
3. Be positive

If you do those three things you have a good chance at being successful third year. A positive personality goes a long way and will often make up for knowledge or other deficits.

 

[ChordaEpiphany]

3/5 is a perfectly fine/average score and is not anything to worry about in and of itself. If you are concerned about this rating, sit down with the clerkship director and ask if he can give you feedback on what you're doing well and how you can improve. Maybe he has some legitimate reason for the score. But also, if there isn't anything specific he wants you to improve on, recognize that not everybody on your rotations is going to like you, and that is fine and won't have a significant impact on your life beyond the few weeks you're with them.

Depends on the school. At my school, a 3/5 puts you in the bottom 10% of the class. Statistically these types of evals are a problem. It's the "wet blanket" effect, where most clinical grades come down to the presence or absence of "wet blanket" (3-bombing) or "5-star" attendings in your eval mix.

It's a problem of prevalence of this type of attending vs. sample size. You need a large sample size of fair evaluations to iron out the variability between students and honest evaluators, but the frequency of "wet blanket" and "5-star" attendings is too high to ever reach a valid conclusion without contaminating the data with these random events.

Score distributions would be much tighter if everyone were a fair evaluator (i.e., wet blankets and 5-stars increase the standard deviation). Accordingly, schools adjust H and P cutoffs. So the actual Honors cutoff is likely an unrealistic expectation, and few-to-none of the M3 students are actually hitting that mark without a 5-star attending helping them get there. The actual Pass cutoff is likely much lower, and few-to-none of the M3 students are actually performing that poorly without a wet blanket pushing them over the edge.

In other words:

H grades are events where students were borderline H/HP AND got a 5-star attending AND didn't get a wet blanket attending.

P grades are events where students were borderline HP/P AND got a wet blanket attending AND didn't get a 5-star attending.

So getting all Hs vs. mostly Hs and 1-3 HPs scattered in is likely stochastic. Students with these grades are holistically and mathematically identical. Ironically, these are also the distinctions that make the biggest difference in residency applications. In the middle, everyone has some mix of H, HP, and P, and the grading system does a pretty good job buffering people at that level. Matching is mostly personality, networking, signaling commitment, board scores, etc... At the top you need all Hs, so you need to get lucky.

 

[Esmolol]

Today, I overheard the nursing staff apologizing to a patient for THE EXISTENCE OF MEDICAL STUDENTS...

 

[MDMechEngr]

Today, I overheard the nursing staff apologizing to a patient for THE EXISTENCE OF MEDICAL STUDENTS...

Need to have thick skin. Unless they are in charge of medical students, such negative comments are irrelevant.

 

[Esmolol]

Need to have thick skin. Unless they are in charge of medical students, such negative comments are irrelevant.

Yeah, I know. I just don't understand the WHY behind it. It's fine. I moved on lol

 

[DarkBluMage]

Today, I overheard the nursing staff apologizing to a patient for THE EXISTENCE OF MEDICAL STUDENTS...

Just ignore them. Some people are just ignorant. I’d doubt they’d say the same about nursing students. Ignore them and keep it pushin

 

[PathNeuroIMorFM]

Probably a final update on this case for those who care:

The clerkship director in my original post did leave the really lame feedback (hinted at during a meeting with my clerkship coordinator), but I was fortunately saved by some really great residents during my last two weeks who wrote me the sweetest, strongest evals that will later make it onto my MSPE. Despite absolutely bombing the shelf exam, I certainly high-passed the rotation and there's a solid chance (knock-on-wood) that I may have even honored this rotation. The important thing is now I know that I CAN be a good student this year, which is a stark difference from me during preclinical.

Now for my current rotation (Ob/Gyn), I'm actually going to certainly not honor, but my feelings wont be as hurt this time lol. It's been a brutal month - both in hours and treatment by faculty - and I'll be happy to just pass this one. I've put in significantly less effort to kiss butt when I know the residents will have no appreciation for it, anyway. Also only like 10-15% of students honor this rotation anyway, so I can't complain. I have no remote dreams of being an obstetrician. My heart is really yearning for pathology right about now haha.

 

[ChordaEpiphany]

Today, I overheard the nursing staff apologizing to a patient for THE EXISTENCE OF MEDICAL STUDENTS...

Med students get an awful reputation in the hospital because we are literally set up to fail. Nursing has taken a mostly rational approach to training their students. Nursing students are in apprenticeship roles. They are introduced to tasks in a gradual and logical progression. They shadow an experienced nurse for a bit, perform simple repeatable tasks in that same environment, and after several weeks at a location they are set off on their own a bit. Med school, in comparison, is pure insanity. Spend 2 years working your tail off while spending almost 0 time on tasks that would help you assimilate to the hospital or practice medicine in a meaningful way. Then spend the next year trying to experience all of medicine in 1 week snippets. With no introduction to the hospital/ward and no training on the EMR, get set free to "pre-round" on patients with no supervision. Stay at that site for anywhere from 3 days to 2 weeks, randomly changing supervisors from day-to-day, and then leave the moment you get even remotely competent. This ensures that you will never be useful, and thus no one in the hospital will ever bother to get to know you or invest in you. Is it really surprising that everyone winds up hating medical students?

 

[RangerBob]

Med students get an awful reputation in the hospital because we are literally set up to fail. Nursing has taken a mostly rational approach to training their students. Nursing students are in apprenticeship roles. They are introduced to tasks in a gradual and logical progression. They shadow an experienced nurse for a bit, perform simple repeatable tasks in that same environment, and after several weeks at a location they are set off on their own a bit. Med school, in comparison, is pure insanity. Spend 2 years working your tail off while spending almost 0 time on tasks that would help you assimilate to the hospital or practice medicine in a meaningful way. Then spend the next year trying to experience all of medicine in 1 week snippets. With no introduction to the hospital/ward and no training on the EMR, get set free to "pre-round" on patients with no supervision. Stay at that site for anywhere from 3 days to 2 weeks, randomly changing supervisors from day-to-day, and then leave the moment you get even remotely competent. This ensures that you will never be useful, and thus no one in the hospital will ever bother to get to know you or invest in you. Is it really surprising that everyone winds up hating medical students?

This is pretty accurate. I will stress that med students are almost never useful. The few times they are (like gathering a really detailed social history the others didn’t have time/interest to do, scut work, etc), doesn’t make up for the time residents/attendings have to put in to educate/train the med student.

But it’s meant to be that way. Med students aren’t supposed to make an attending or resident more efficient. Their job is to learn, and it’s to learn more than tasks/protocols like what a nursing student learns. Med students are learning to think in medical terms. Nursing is less critical thinking more action based (not a criticism against nurses, and it’s part of why patients like their nurses more), so the “learn by doing” really works well for nurses.

Med student teaching could still absolutely be done better. And it could be less demoralizing to med students. Everyone loves nursing students—they’re young, eager, and really motivated to help. Med students are the same (just note quite as young, bright eyed/bushy tailed), yet we don’t let them help much/enough. I can’t begin to say how many visiting DO students I met who said they literally shadowed on core (FM, IM, surgery, etc) rotations.

“But that’s the way it’s always been done”

 

[ChordaEpiphany]

This is pretty accurate. I will stress that med students are almost never useful. The few times they are (like gathering a really detailed social history the others didn’t have time/interest to do, scut work, etc), doesn’t make up for the time residents/attendings have to put in to educate/train the med student.

But it’s meant to be that way. Med students aren’t supposed to make an attending or resident more efficient. Their job is to learn, and it’s to learn more than tasks/protocols like what a nursing student learns. Med students are learning to think in medical terms. Nursing is less critical thinking more action based (not a criticism against nurses, and it’s part of why patients like their nurses more), so the “learn by doing” really works well for nurses.

Med student teaching could still absolutely be done better. And it could be less demoralizing to med students. Everyone loves nursing students—they’re young, eager, and really motivated to help. Med students are the same (just note quite as young, bright eyed/bushy tailed), yet we don’t let them help much/enough. I can’t begin to say how many visiting DO students I met who said they literally shadowed on core (FM, IM, surgery, etc) rotations.

“But that’s the way it’s always been done”

I appreciate the vast difference between nursing vs. med school. However, it still absolutely doesn't have to be this way. Med school (and residency to a lesser extent) has been made unnecessarily stressful by very short stints on services. You spend enormous time and mental energy learning the basics of your work environment. When you do 1-2 week stints, you spend all your time learning a new building, EMR, note preferences, presentation preferences, workflows, etc...

This mental strain absolutely takes away from learning, performance, and patient care while adding hours to each day. How can you possibly think about medicine when you're simultaneously juggling stuff like, "Don't editorialize vitals for this attending" "Where do I find the assigned nurse for this patient?" "My patient is apparently in the west hallway, where is that?" "How do I submit a progress note on this EMR?" "What is the preferred format for notes on this service?" "I don't know how to parse efficiently through notes from frequent referring services to get frequently needed information," "Where is the bathroom?" At least 75% of my day as a medical student is spent fussing over these things. I barely have time to think about the patients, let alone do the stuff attendings are asking for, like comparing and contrasting recommendations from specialty organizations. I'm mentally and emotionally exhausted from being primarily judged by my mostly non-medical performance in the first few days of existing in a brand new environment.

A very simple solution would be an abbreviated pre-clinical curriculum and longer rotations. Instead of an 6 week peds rotation covering the floor, PICU, peds ED, nursery, outpatient, and nights for 1 week each, how about a 10 week rotation of 4 weeks floor, 4 weeks outpatient, and 2 weeks of PICU, NICU, nursery, or ED? Let the students get into a groove of some sort so they can focus on the medicine. Give them actual time with the attending for meaningful evaluations. My first rotation was 3w + 3w and I was genuinely a helpful member of the team by week 2 and was actually having fun by week 3. Residents were genuinely glad I was there to lighten the load. My second rotation has been 1 week stints, and I'm just a burden. Residents are baseline annoyed at med students so rarely teach. Attendings give average marks to every student and often never see them present or interact with a single patient. Evals are 70% of our final grade, and this is what determines my future? It's lunacy.

 

[RangerBob]

I appreciate the vast difference between nursing vs. med school. However, it still absolutely doesn't have to be this way. Med school (and residency to a lesser extent) has been made unnecessarily stressful by very short stints on services. You spend enormous time and mental energy learning the basics of your work environment. When you do 1-2 week stints, you spend all your time learning a new building, EMR, note preferences, presentation preferences, workflows, etc...

This mental strain absolutely takes away from learning, performance, and patient care while adding hours to each day. How can you possibly think about medicine when you're simultaneously juggling stuff like, "Don't editorialize vitals for this attending" "Where do I find the assigned nurse for this patient?" "My patient is apparently in the west hallway, where is that?" "How do I submit a progress note on this EMR?" "What is the preferred format for notes on this service?" "I don't know how to parse efficiently through notes from frequent referring services to get frequently needed information," "Where is the bathroom?" At least 75% of my day as a medical student is spent fussing over these things. I barely have time to think about the patients, let alone do the stuff attendings are asking for, like comparing and contrasting recommendations from specialty organizations. I'm mentally and emotionally exhausted from being primarily judged by my mostly non-medical performance in the first few days of existing in a brand new environment.

A very simple solution would be an abbreviated pre-clinical curriculum and longer rotations. Instead of an 6 week peds rotation covering the floor, PICU, peds ED, nursery, outpatient, and nights for 1 week each, how about a 10 week rotation of 4 weeks floor, 4 weeks outpatient, and 2 weeks of PICU, NICU, nursery, or ED? Let the students get into a groove of some sort so they can focus on the medicine. Give them actual time with the attending for meaningful evaluations. My first rotation was 3w + 3w and I was genuinely a helpful member of the team by week 2 and was actually having fun by week 3. Residents were genuinely glad I was there to lighten the load. My second rotation has been 1 week stints, and I'm just a burden. Residents are baseline annoyed at med students so rarely teach. Attendings give average marks to every student and often never see them present or interact with a single patient. Evals are 70% of our final grade, and this is what determines my future? It's lunacy.

Sorry if it seemed I suggested otherwise, but I completely agree with you. Learning the workflow/logistics/etc is horrible. I can't say how thankful I was when I started my PM&R residency and the standard was two months for each rotation.

Still, with that said, on many two month outpatient rotations I might be with on particular attending each Monday, and another Thur PM, etc. I by far learned the most (medical knowledge and general logistics/throughput) when we did the bulk of the rotation with a single attending.

1 week rotations are completely useless, for the very reasons you point out.