3rd Year Med Student

[Kgizzle]

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Hey I was just wondering what sort of practical skills a 3rd year med student has. Other than being to do an H&P and take vitals, ROS...what are 3rd years supposed to know at the beginning of clerkships?t

 

[munchymanRX]

Hey I was just wondering what sort of practical skills a 3rd year med student has. Other than being to do an H&P and take vitals, ROS...what are 3rd years supposed to know at the beginning of clerkships?t

Those skills, and also the ability to shoot lasers out of your eyeballs.


Seriously though, as a 3rd year medical student doing rotations the answer is not much. I have friends who aren't even allowed to touch a patient until their 4th year, and anything you do will be under close supervision and extremely limited. You play the role of an observer (and for a lucky few of us, a hands-on one). You'll really learn how to be a doctor in your residency.

 

[spicedmanna]

Hey I was just wondering what sort of practical skills a 3rd year med student has. Other than being to do an H&P and take vitals, ROS...what are 3rd years supposed to know at the beginning of clerkships?t

Really, you aren't expected to know much at the onset of your third year. Everyone knows that you were stuck in a classroom for two years prior. Anything you do know from the onset is a bonus. Your role as a third year student is to learn. Period. Nobody expects much, except that you show up on time, help where you can, and come in with a good attitude that demonstrates that you are there and eager to learn.

The most important thing to have some idea of as you start, which will make it easier, is how to perform a good, complete (as well as a focused) history and physical. This is actually more complicated and involved than you think. You can teach technique and skills, but only by experience can you learn how to hone in on exactly how to talk to the patient, get him or her to trust you enough to reveal what you need to help them, and to refocus them when they get off track. Just wait until you see some of the choice patients out there...it can really be a challenge.

Learn how to come up with a reasonable differential. This is very important skill. Again, this is not so easy to do succinctly. Almost everyone can spew out a dozen things given a set of presenting signs and symptoms, academically, but it's more difficult to come up with a realistic list of the most likely, along with important rule-outs, based on available data, and then come up with a reasonable initial work-up. In particular, you don't want to miss the ones that will kill the patient or will result in rapid decompensation. Practice, practice, practice.

Learn how to ask, "what's the next step?" If you don't know the answer, learn how to use available resources to find out...and quickly. Not only is a lot of clinical medicine based on this skill, your Step II/COMLEX II is going to be based on your ability to answer this question.

Learn how to write a good, accurate, and succinct SOAP note. Again, this takes practice. Look at good models and ask for feedback. Refine. Repeat. Also, you'll learn that each field/rotation you are on, has slightly different expectations for the SOAP note. A surgical SOAP note is not the same as a medicine SOAP note, is not the same as an FM office note, or an OB note, etc.

Learn how to present your patient to your attending and to a resident, succinctly and accurately. This is very hard to do. The more practice, good feedback you get, the better. You'll refine and refine, until you are able to present a very complex patient in just a few sentences, catching all the important details, yet keeping it simple and short enough to satisfy even the most busy attending.

Learn how to use your stethoscope correctly. It's not just a necklace you hang around your neck to look cool. I'm serious. Learn how to listen with it and how to identify critical findings. You'll like like a champ if you can do that. This takes a lot of practice.

Learn how use other important medical equipment. You'll pick this up as you go. You'll learn how to discern normal findings from abnormal findings.

READ about your patients! Try to pick up the basics of work-up and management of these patients. This is where a lot of the learning comes from: your own leg work. This is expected. Everyone is busy as heck on the wards, and if you get some instruction, it's a bonus. Learn to observe how it's being done. Sometimes that's the only instruction you are going to get. Also, if you ask questions to someone more senior to you, make sure you have some baseline knowledge and took the time to research some of it first. You'll look like an idiot if you ask something obvious or that could be looked up. And you may suffer a lot of pimping from that.

Get involved in procedures where you can.

Be nice to the nurses and ward clerks. They are your friends and allies. Make them your friends. They can make you look cool, teach you a few tricks, warn you about the very stupid mistakes you are about to make, and keep you informed about your patients, or they can ruin you.

Other than that, come in with a good attitude, be open and eager to learn, show up on time, and offer to help when you can.

 

[Kgizzle]

Thx for the answer spicedmanna...so basically 3rd year is more observational than procedural that's good to know. Oh well, I guess I'll have to wait till residency to save the world 🙄

 

[spicedmanna]

Thx for the answer spicedmanna...so basically 3rd year is more observational than procedural that's good to know. Oh well, I guess I'll have to wait till residency to save the world 🙄

Not necessarily. It depends on the hospital/office where you are doing your rotations. At my core site, I did a lot. On the wards, it's a whole lot more formal. That is to say, you will wake up before everyone else and pre-round on your patients and write your progress notes. Your resident will help you with this and see the patients with you at first. As you gain more experience, they may just assign you patients to follow up on and then check on you, your patient, your note, and for any orders that need to be written. Over time, when your abilities get better and trust is built, your resident(s), may give you more autonomy and tasks to do. At some point during my third year, my residents trusted me to see new patients, write initial consults and orders, and then present the patient to them, without the need for hand-holding. As you become even more experienced, on pre-rounds, you may even start anticipating which orders need to be written, write them, and then bring it over your resident. Before the Attending arrives to round with the team, you will round with your residents to hash out what is left to be done. When you round with your resident, you will see how he or she does things. Then, after all that is done, you will round with your entire team, which consists of all the residents and your Attending. Again, you will see how they do things. This is where you may have the chance to present the patient to your Attending. Throughout the day you will continue to follow up on your patients, and depending on your level of skill, by yourself or with your resident or both.

Obviously, I'm talking primarily of medicine-based rounds and day. If you are on surgery, you are going to follow up on admitted surgical patients, pre- and post-surgery, in the morning and throughout the day. Some surgeons round with you, while others, will not, and you just follow up with the resident. Throughout the day there will be surgical cases, and depending on the hospital or surgeon, you will have various levels of involvement, consisting of observing, suturing, being a human retractor, or even the level of first assist.

In the office setting, your resident/preceptor will have you observe until they feel comfortable with your abilities, then you will see patient first, write your SOAP note, make suggestions on assessment, treatment, and work-up plan, followed by the preceptor/resident going in with you to see the patient.

 

[spicedmanna]

If it makes you feel any better, I did quite a good amount of procedures during my third/fourth year. I did about 25-30 intubations, sutured a fair amount of surgical and traumatic wounds, I&D of abscesses, tried my hand at about 5 central lines, 4 arterial lines, involved in a code or two, helped reset some broken bones, delivered a couple of babies, did a lot of pelvic exams, rectals, etc. You'll get to do things, it just isn't expected, but when they present themselves, try to get involved.

 

[Kgizzle]

Gracias. It's good to know that I will at least get some hands on experience

 

[fiznat]

Great posts, spicedmanna!

 

[DocDanny]

I got to put in a PEG tube. That was kinda neat.

But no other procedures. Unless you call a rectal exam a procedure.

We aren't expected to know how to do all the paper work, are we?

 

[spicedmanna]

We aren't expected to know how to do all the paper work, are we?

If by paperwork, you mean SOAP notes, then, yes, you are required to know how to write those. In fact, you'll be writing LOTS of those, especially in the form of progress notes. You do get guidance and feedback though. Most places will probably require you to write complete H&P's on new admits, especially on medicine. Depending on where you rotate, you may be expected to write some initial admit orders, discharge orders, OB/delivery notes, and/or consults to the service you are on, but only after getting some instruction on it. There are other kinds of notes that would be good to know how to do, but it's not necessarily required, for example, procedure notes. I was never required to write a procedure note, other than an OB/delivery note, or some minor office procedures. However, after some experience and instruction, I did sometimes help with some more complicated procedure or OP notes; it's often seen as a bonus skill, rather than a requirement.