Advice for those starting 3rd year clerkships

[spicysoup55]

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Since many schools are starting 3rd year clerkships within the next few months, can people offer some advice for us? How have you been able to learn as much as possible (and get good grades) on your clinical rotations? Thanks in advance for your help!

 

[Cytarabine]

Always be early. Never lie. Help your team. Never show up or make a superior look bad. Read on patients to the extent you can but ultimately your grades prob going to be more dependent on your shelf and shelf-focused studying. Read in your downtime on service. The earlier you can make it through reading information the more you can get out of your clinical time (applying what you read to patients)

 

[Psai]

Resident: Did u check pulses?

You: Yup they were good, 2+ dorsalis pedis

*walk in and see wheelchair in patient's room, bilateral akas

Don't do this. Better to admit you didn't do something and look stupid than make something up and look like a liar

 

[Hangry]

Since many schools are starting 3rd year clerkships within the next few months, can people offer some advice for us? How have you been able to learn as much as possible (and get good grades) on your clinical rotations? Thanks in advance for your help!

I posted about this in another thread on this forum just the other day: http://forums.studentdoctor.net/threads/prep-for-clinical-years.1192282/#post-17609975

In short: study some every day. Pick some resources you want to cover for the rotation using the clinical rotations forum/shelf threads, then determine how many questions/pages/videos you need to do per day to get through that resource in a reasonable amount of time. Then get through that much material no matter what. That should be the bare minimum you do every day, on top of that, read on your patients' various conditions using resources like medscape and uptodate when you get the chance. Of course, also look up any pimp questions that day that you didn't know so you are ready if they ask you something again.

Of course don't forget to find time to exercise, sleep, and take care of yourself, but realize that depending on the rotation you are going to have much less time for that than you did in years prior. Medicine becomes a job this year, for better and for worse.

 

[Tenk]

If you can google it, don't ask it.

 

[Mr Roboto]

@mimelim wrote the classic post on this.

 

[mimelim]

@mimelim wrote the classic post on this.

You mean this?

http://forums.studentdoctor.net/thr...etent-fool-on-rotations.988111/#post-13752337

I just did evals for our medical students from February. Supposedly the clerkship director will edit/review them, but I kinda doubt it since what I wrote will be more detailed than he could ever write based on his interaction with them which was minimal.

I will only talk about surgery clerkships since that is what I know. A lot of this will apply to other clerkships that others can adapt. I can give specific examples for every single number below based on last month alone. These are very common issues.

To avoid being a bad student:
1) Show up on time
2) Look professional
3) Be available. You should never disapear and unreachable.
4) If asked to do something, either say, "Yes, I'll do it" or, "I don't feel comfortable with that, do you mind teaching me how to do it so I can do it next time?"
5) Do not ask "Anything that I can do right now?", ask, "How can I help?" or simply offer to do things, I hate scutting stuff to students, but if you offer to drop my notes off for me, or you feel comfortable finishing a dressing change on your own, if you say, "I can handle this" or just "I got this".

To be a good student:
1) Know your patients inside out and backwards. You are carrying less patients than your residents/attendings, you should know the details about your patient, even if they don't. You may not know what it means, but you should have the info available.
2) Always make an assessment, attempt to develop a plan. Start with a wide differential and focus in on the most likely diagnoses.
3) Read. Every night, even if it is for 15 minutes. Read about your patient or the procedure they are about to have or have had.
4) Be helpful. Getting labs, dropping notes in charts etc. Scut sucks, we all have to do it.
5) Tie and suture. I will walk anyone through how to do something, but I expect you to know the basics before showing up in the OR. If I show you how to do something, you should practice it at home and if you don't get it, ask me to show you again when we have down time.

To be a rock star:
1) Know your patients inside and out, but pay attention to what residents and attendings find important. Nobody will fault an MS3 for giving a laundry list of normal physical exam findings/labs, but eventually you have to learn to focus in on the important things so you can effectively communicate with colleagues down the road.
2) Develop skills. You are as useful as the skills that you posess. Things that an MS3 could potentially know how to do solo or with only resident observation:
a) Wet to dry dressings
b) Wound vac exchanges
c) Chest tube placements
d) Chest tube removals
e) Suturing - Simple, horizontal matress, vertical matress, sub Q, deep dermal, running
f) Central line placement
g) Central line removal
h) Fever workup
i) Getting outside hospital records
3) Learn to solve the common problems. Every rotation, go to the charge nurse on your main floor and ask them what the 10 most common intern calls are for. They should sound like this: Pain, fever, nausea, tachycardia, hypertension, electrolyte abnormalities etc. And then the specifics, Vascular: loss of previously dopplerable pulse, Gen Surg: change in abdominal exam findings etc. Then learn how to work up or manage those issues. As an MS4 on sub-I a good student will function like an intern. Those skills don't show up overnight, you have to develop them over time starting as an MS3.
4) Do not stop suturing or knot tieing. If you are interested in surgery, innate ability counts for something, but more important is practice. You should be able to do one handed ties left and right handed with ease. You should be efficient and accurate. When in conference, tie to your scrub bottoms or the chair next to you. If you have down time, have someone check your technique.
5) Think before cutting suture. What kind of suture are you cutting? Where are you cutting it? What is the purpose of this stitch? How many knots were tied? There is a logic behind suture tail length. While you will always have people that do things a particular way "just because", the vast majority will have a method behind their madness.

 

[Sea Otter]

Don't tell a paralyzed person to ambulate. Don't stick out your right hand to shake a patient's right only to realize they only have one arm...their left.


Sent from my iPhone using SDN mobile app

 

[TBV]

Wear pants. Wear pants every day.

 

[themockjock]

Don't be a cock. This seems self-evident, but you would be surprised at just how poorly some people follow this. Partly this is probably because I think at least a little bit of a personality disorder is a requirement to get into med school, but also because you're used to a certain amount of deference and respect from society as a whole when you tell them you're in med school (you know that "oh, so you aren't a f*up" look that family friends etc. get when they find out) and once you get into the hospital, you aren't **** and people sometimes treat you terribly and those personality disorders in med school carry over to the residents and attendings and they will sometimes treat you like ****. So, when you're particularly beaten down (or just are a cock in general) it's easy to snap, make some comment, be arrogant, etc. DON'T. You would be amazed at how easy it is to get great evals just by showing up and being nice and having people like you even if you are a complete abject idiot who couldn't tell COPD from erectile disfunction. On the flip side, if one of your residents (or worse many of them) don't like you because of some comment or whatever, you are totally sunk even if you generally try and be nice after that. On peds I remember a guy who was just weird and arrogant pissed off the residents and it was hilarious to watch them absolutely destroy him over the next few weeks, even though he was reasonably smart. Errors in knowledge will be forgiven, errors in personality will not.

On that note: SPEAK UP. On rounds, in conference, whatever. It is REALLY easy to disappear during the rotation and that is a passport to straight satisfactory grades. The wards aren't a UWorld question; it's fine to get pimp questions wrong (just be able to tell COPD from ED... beyond that expectations are low). I generally think that attendings view med students as baby seals whom they can club with their giant club of knowledge and they don't expect you to put up a fight about it. And often, they like you to speak up and answer questions because everybody likes to think that people are paying attention to them. Even if the people paying attention to them are idiots.

You will do scut work (ESPECIALLY on medicine). And it sucks. The amount of scut will vary from rotation to rotation, but it will be there. Even though it sucks, you will be amazed at the difference in being on a well-run service versus on a poorly-run service. Everybody is happier on well-run services and there is generally more time for teaching, learning, and just getting to know the team (again, if your evaluators know you and you asked about their kids or something... more likely to give you honors than just some interchangeable face in a short white coat). I would argue that it's better grades-wise to be a mediocre student on a great service than a great student on a horrible service. So, do your scut work if it means making everybody happier. Call social work, get discharge papers in order, track down outside records, etc. I ****ing hated every second of doing stuff like that but I really think that it pays off in grades.

On reading: Everybody will tell you that you have to read every night when you get home. I think that is COMPLETELY unrealistic. Probably 90% of the nights all I wanted to do when I got home was open a beer and watch ****ty TV. So I figured out how to adapt. If you haven't already realized it, as a med student, there is quite a bit of downtime during the day throughout the hospital. Usually in 15-20 minute random blocks while waiting for records, a page back, the attending to show up, etc. Most people sit on their phones and go on snapchat or something during this time. I would read on UpToDate or the green book or whatever in these little blocks. Read about your patients, read about something you've forgotten about, whatever. I probably averaged 90 minutes to 2 hours of reading throughout the day in little chunks. Even though it feels like you aren't reading and learning things, you are. On medicine for example I barely read when I got home and honored the shelf by a wide margin because of all the reading during the day.

 

[Dires]

1. Biggest thing is to be interested. Residents and attendings take a bigger interest in you if they see you care about the rotation and learning. Interest in you = more conversation = bond = good eval
2. Actually give an F about your patients. Treat them like humans. Don't stroll cyborg style with a stick up your ass all the time. Patient tells attending they like you = golden eval.
3. "Working hard" has been covered above. Most schools have shelf cut offs for grades.
4. Be a team player, don't be lazy, and don't be a dick to anyone (nurse, fellow MS, or any other provider). If someone is rude to you, apologize and move on. No drama
5. Don't be afraid of being wrong. You're a student and there to learn.
6. Always have an assessment and plan. I don't care if your blasting someone with vanc zosyn for community acquired pneumonia. Say something confidently.
7. Have a short term memory when it comes to ****ing up, because you'll be doing that daily.

 

[madchemist89]

Be likeable. It's that simple. You may ask how do I do that? Others have already given a myriad of examples of how to be more likeable already. Knowing your patients makes you more likeable. Being available on time and prepared makes you more likeable. Being polite makes you more likeable. In a subjective evaluation, there is no objective marker on which to compare students. Those students who are more liked will do better. It all comes down to your interpersonal skills.

 

[sliceofbread136]

You wanna know the real way to do well? Hope you get easy attendings. In the end that is all that matters, you could be a rock star but if you have an ahole of an attending you still get a pass. Then there are the attendings that give everyone honors. Third year is simply a poorly designed crap shoot.

The best way to ensure good third year grades is to go to a school where most of it is based on your shelf and just kill the shelf

 

[Akali]

I'd like to emphasize the saying "Is there anything I could help you out with?" when you med students have down time. Of course, you have to act like you genuinely wish to help out whether or not you actually do. I've personally gotten a lot of value out of it, or at least I feel like I did, and it's such an easy thing to do. The best part about it, at least in my experience, is that the majority of the time they're not going to have anything for you to do. Aside from scutwork, there isn't much you actually can do as a medical student that is of practical use - that's why you have downtime. So you end up not having to do anything extra (i.e. getting to go back to studying for your shelf exam) and they have a reason to give you a good evaluation. But like that surgeon also noted, be very sure to not come off like you are bored and/or suggesting you want to leave. You'l feel like your time is being wasted and you should be let out, but attendings and some residents will have this idea that there is like a million things you should be doing (studying for your shelf not being one of those things even though it'll be the one thing you actually want to do). And if it's within their power, occasionally the residents will actually let me leave after I ask that and they say there's nothing I can do.

Some rotations are going to suck really, really hard and you're not going to want to do **** at all when you finally get home exhausted, but still try to get an hour of studying each day for your shelf so you can honor it. Obviously, some people need to study more or less than others though.

 

[starstarie]

In addition to all the great comments above, I would add one thing that I sometimes struggled with in retrospect.

Think about your role as a student, and work towards improving this. This will change depending on the service, and it will change based on who exactly is evaluating you (attending vs resident vs multiple people's input).

As an older student who has had a "real" job, I learned by emulating what others were doing, and focused on that. However, as a medical student this is not necessarily your role. For example, you can't always glaze over the VS and PE in your presentation (at least in internal medicine), like a surgery intern will. Your presentation as a med student (esp 3rd year) is a big part of what they are evaluating. Although you might be working your butt off to help the team, if your attending is the one evaluating you, all that energy spent may not pay off (not saying you shouldn't do so, but just be aware).

In the OR a student is supposed to know the anatomy for the possible questions. Even if you plan of going into surgery, anything above basic knotting and suturing, is not really what you will be evaluated on.

And even if you play ALL your cards right, it will probably just come down to the shelf.

 

[DrYoda]

Study whatever material is recommended or you prefer for the shelf as this is likely as others have noted going to be a large portion of your grade and the one you have the most control over. Additionally what you learn clinically on your clerkship is important knowledge, however how heavily it is emphasized on the shelf will vary. Clerkship evals to be honest are largely going to depend on how much the residents/attending like you, some of this will be based on presentations, hard work ect but a lot of it is going to boil down to personality which is a harder thing to alter. Hell as mentioned above there are attendings that honor everyone, and those that never honor everyone so a degree of luck is involved.

As far as presentations go: if you have a chance and at least on my clerkships we often did, run your plan over with a resident prior to presenting to the attending (and by resident- not an intern early in the year). The residents know the workups, pimp questions and attending practice preference and will make you look a lot better than if you just dry run the presentation to the attending. More variable on other services, in the ED generally we always go over stuff with students but there's always the one that wants to just wander up to the attending by themselves and present. You will look a lot better if you run though the patient with a 2nd+ year resident first.

Follow up on your patients. This would seem obvious but a lot of students, at least in the emergency department setting, go see and present a patient and then basically forget about them unless there's a procedure I grab them to help with. This doesn't mean you need to update me every time a normal piece of labwork comes back, but we do notice it when you are paying attention to what is going on with your patients. This is what you will be doing as a resident and attending so might as well start now.

Procedural skills are largely a learned thing, granted there are some people that are innately better than others. I've just recently got back to posting regularly on here but there have been multiple threads lately about degree of procedural competence and it's affect on evals/grades. I generally don't expect a lot out of students, especially for big procedures that is what residency is for. Do however know procedural landmarks, indications and contraindications for the big procedures of that specialty as they are popular questions. your ability to do them on the other hand I think matters less. Do learn how to suture and be able to one-hand tie with both hands, if it's your first procedural oriented specialty have someone walk you through this and then steal some suture and practice.

Don't be a cock.

And yeah basically agree with this whole post. It's shocking the number of people that have an inability to do this. Some of it may be the personalities in medicine in general. Some of it, I think, is that many students have a hard time or just straight up don't realize they are now at the very bottom of the totem pole during third year clerkships. This does suck but eventually gets better. Just try not to piss anyone off.

 

[Cinclus]

The best way to ensure good third year grades is to go to a school where most of it is based on your shelf and just kill the shelf[/QUOTE]


I wish this was something I had known. I would have absolutely destroyed 3rd year if my school put more emphasis on objective measures.

 

[HelpPleaseMD]

You wanna know the real way to do well? Hope you get easy attendings. In the end that is all that matters, you could be a rock star but if you have an ahole of an attending you still get a pass. Then there are the attendings that give everyone honors. Third year is simply a poorly designed crap shoot.

The best way to ensure good third year grades is to go to a school where most of it is based on your shelf and just kill the shelf

completely disagree. I thought the same way as you did as a med student, but if you actually did go to such a school, I cannot imagine students caring two ****s about anything clinical and would do whatever they can to study for the shelf. thats just a repeat of the MS1 - MS2 years. 3rd/4th year is when you start learning the skills to be a good clinician. I agree that it is not designed that well... but thats another story

 

[Okazaki Frag Grenade]

How do you find out how the school would handle shelf grades in relation to the rest of the evals for rotations?

 

[gobigorgohome22]

How do you find out how the school would handle shelf grades in relation to the rest of the evals for rotations?

This should be something that your clinical dean or someone is similar position makes clear to you before you shift off to rotations. You can always talk to upperclassmen to figure out how its done as well.

 

[akwho]

People will tell you 3rd year grades are random, but they're not. Perhaps you can get unlucky, or lucky, on 1-2 rotations throughout the year, but by the end of 3rd year a pattern will exist that tells the story of your clinical skills. People that regularly read applications for residency know this and look for patterns in evaluations. A student with 4H and 2HP is much different than a student with 1H and 5HP, the former is generally exceptional and the second is generally above average. Is there really a difference between a student with 3HP 3P and one with 2HP and 4P?? Not enough of a difference to be significant, they are both probably below average on the wards.

To consistently get good grades 3rd year, you need to do EVERYTHING well:

1. You need to maximize the objective portions of your grade (shelf exams, physical exam CEX's, clinical OSCE's, patient write-ups, teaching presentations), which are truly under your control and fairly formulaic. Study hard, use review resources, talk to people who have done the rotation before you, prep well for OSCE's and teaching presentations. Be an independent, motivated learner, and know more for your level than expected.
2. The clinical portion of your grade is basically dependent on 1) if everyone on your team likes you, 2) if your patient's like you and say good things to the team, 3) if you shine in the few moments when your graders actually assess your knowledge. This basically entails being friendly, professional, and always willing to help the team. When your graders actually take the time to assess your knowledge, you have to be ready. This means always being up to date on what is happening with your patients, appropriate treatment regimens and pathophysiology, when pimped give a clear concise answer that demonstrates the depth of your knowledge on the subject, then shut up and let the attending give the teaching point they wanted to emphasize in the first place.

 

[sliceofbread136]

completely disagree. I thought the same way as you did as a med student, but if you actually did go to such a school, I cannot imagine students caring two ****s about anything clinical and would do whatever they can to study for the shelf. thats just a repeat of the MS1 - MS2 years. 3rd/4th year is when you start learning the skills to be a good clinician. I agree that it is not designed that well... but thats another story

I actually feel I learn better when I don't have a grade hanging over my head. I can push myself and make mistakes, the real way to practically learn. When I am being graded I have to keep it safer.

People will tell you 3rd year grades are random, but they're not. Perhaps you can get unlucky, or lucky, on 1-2 rotations throughout the year, but by the end of 3rd year a pattern will exist that tells the story of your clinical skills. People that regularly read applications for residency know this and look for patterns in evaluations. A student with 4H and 2HP is much different than a student with 1H and 5HP, the former is generally exceptional and the second is generally above average. Is there really a difference between a student with 3HP 3P and one with 2HP and 4P?? Not enough of a difference to be significant, they are both probably below average on the wards.

To consistently get good grades 3rd year, you need to do EVERYTHING well:

1. You need to maximize the objective portions of your grade (shelf exams, physical exam CEX's, clinical OSCE's, patient write-ups, teaching presentations), which are truly under your control and fairly formulaic. Study hard, use review resources, talk to people who have done the rotation before you, prep well for OSCE's and teaching presentations. Be an independent, motivated learner, and know more for your level than expected.
2. The clinical portion of your grade is basically dependent on 1) if everyone on your team likes you, 2) if your patient's like you and say good things to the team, 3) if you shine in the few moments when your graders actually assess your knowledge. This basically entails being friendly, professional, and always willing to help the team. When your graders actually take the time to assess your knowledge, you have to be ready. This means always being up to date on what is happening with your patients, appropriate treatment regimens and pathophysiology, when pimped give a clear concise answer that demonstrates the depth of your knowledge on the subject, then shut up and let the attending give the teaching point they wanted to emphasize in the first place.

Maybe it's the school I go to, but in my experience people like you are completely delusional. Your likability and clinical knowledge probably arent as great as you think they are.

 

[sliceofbread136]

So baylor is equally bullcrap huh? I wonder if there is any school in Texas that does it better

 

[akwho]

I actually feel I learn better when I don't have a grade hanging over my head. I can push myself and make mistakes, the real way to practically learn. When I am being graded I have to keep it safer.

Maybe it's the school I go to, but in my experience people like you are completely delusional. Your likability and clinical knowledge probably arent as great as you think they are.

Top 5% of class in boards, and clinical grades at a top-10 medical school. I've read 100's of peer applications for AOA. What are you qualifications wonderbread? Glad you do better when everyone covers their eyes when you're examining a patient.

People like you, can't accurately judge your performance against your peers because you've got to much arrogance. Your classmates are really, really good. You aren't the big kahuna anymore like in high school or college. Your average grades are just that, average. But being in the middle of an exceptional herd, isn't such a bad thing if you would just stop deluding yourself.

 

[sliceofbread136]

Top 5% of class in boards, and clinical grades at a top-10 medical school. I've read 100's of peer applications for AOA. What are you qualifications wonderbread? Glad you do better when everyone covers their eyes when you're examining a patient.

People like you, can't accurately judge your performance against your peers because you've got to much arrogance. Your classmates are really, really good. You aren't the big kahuna anymore like in high school or college. Your average grades are just that, average. But being in the middle of an exceptional herd, isn't such a bad thing if you would just stop deluding yourself.

Wow you must be really smart! Thanks for opening my eyes by listing your stats!! Should I list my school rank too? It's funny how perfectly you fit the person I was describing earlier

You are incorrect in assuming my grades are average, I am a very good test taker and also did well on my boards and rotations. I do agree my classmates are very smart and 80% all of us are killing it. So what's causing the stratification of grades? You guessed it, what attending they were assigned to. I usually get pretty lucky but it makes me equally mad seeing one of my peers get short changed.

 

[Duke1K]

People will tell you 3rd year grades are random, but they're not. Perhaps you can get unlucky, or lucky, on 1-2 rotations throughout the year, but by the end of 3rd year a pattern will exist that tells the story of your clinical skills. People that regularly read applications for residency know this and look for patterns in evaluations. A student with 4H and 2HP is much different than a student with 1H and 5HP, the former is generally exceptional and the second is generally above average. Is there really a difference between a student with 3HP 3P and one with 2HP and 4P?? Not enough of a difference to be significant, they are both probably below average on the wards.

To consistently get good grades 3rd year, you need to do EVERYTHING well:

1. You need to maximize the objective portions of your grade (shelf exams, physical exam CEX's, clinical OSCE's, patient write-ups, teaching presentations), which are truly under your control and fairly formulaic. Study hard, use review resources, talk to people who have done the rotation before you, prep well for OSCE's and teaching presentations. Be an independent, motivated learner, and know more for your level than expected.
2. The clinical portion of your grade is basically dependent on 1) if everyone on your team likes you, 2) if your patient's like you and say good things to the team, 3) if you shine in the few moments when your graders actually assess your knowledge. This basically entails being friendly, professional, and always willing to help the team. When your graders actually take the time to assess your knowledge, you have to be ready. This means always being up to date on what is happening with your patients, appropriate treatment regimens and pathophysiology, when pimped give a clear concise answer that demonstrates the depth of your knowledge on the subject, then shut up and let the attending give the teaching point they wanted to emphasize in the first place.

100% agree.

 

[Crayola227]

I'm now with the educators who I used to hate that say "there is no such thing as scut, it's all educational," within reason

scut is basically everything you think a doctor shouldn't have to do because it shouldn't really take an advanced healthcare degree worth $250K to do it, but within that there's 2 kinds

the scut we all have to do as doctors, at either the intern level, or beyond
and scut that truly is bull****

e.g. getting medical records
it is a waste of time for a doctor to do this, and the best institutions have figured this out and come up with a solution, however many places many times if you want the info you have to get it

vs

e.g. stapling 20+ handouts for morning report tomorrow

Both should of course be done by med students with a smile, and a "please sir, can I have s'more?"

I "scutted" out my med students the way I *wish* I had been scutted out to prepare for intern year. I would have them run the list with me and anything within their power to do I would have them do on their patients.
I made sure this sort of work wasn't interfering with the typical expectations of students or keeping them any longer than an hour a day, when said hour wasn't making them stay too long. Call me a dick but getting them out ASAP was not my number one goal, teaching them all the things I wish I had known intern day #1 was. (this goes more for the subI's than the MS3s, but still)
- how to put in orders (my residents were too lazy to cosign orders... so I never got to practice. That's bad. It's good to actually do it yourself as it helps force you to learn a system for all things order related. I would put them in charge of order sets like for bowel regimen, orders that make nightfloat's job easier (protocol/comfort driven orders). I would have them put in daily labs a few times, so they would think more critically about whether or not a lab was needed. It's often pointed out here that one is more likely to remember to follow up on lab order they themselves have placed. I would walk them through the math of calculating insulin dosing, etc
- how to order electrolytes (never had to do this... never learned until day 1 of internship, this little chore on top of all the rest... grrr)
- updating sign out sheet
- how to get a hold of people in the hospital... pharmacy, tele, SW, etc and outside the hospital, like PCPs
- putting in consults like to SW
- filling out nursing home dc forms
- switching IV meds to oral... and figuring out the dosing, there's a lot EHRs can hold your hand for, but some of it you have to figure out yourself
- calling nurses back (sometimes appropriate for them to do)
- calling EHR helpdesk when we didn't know how to do something

A lot of people take the attitude that the med student should just be doing notes and presentations, and primarily focussing on how to do those things well, is super important. But the question gets asked here how to do better and help the team and be liked.

My advice, if the intern is doing it, then it's something you want to know how to do. If they intern says, "do you know how to find ___" and the answer is no, then you want to figure it out. If they look exasperated that you don't know how to do it because it was going to save them time and now they look sad, at that point or end of the day beg for them to teach you. Those are the things that makes their life easier which is a good thing now, but is also good later on down the line, and you will be glad to have a handle on before you toss more on your plate as an intern.

Some people will say so much of the above are systems issues and particular to only one hospital setting so how is learning it going to help down the road, but the whole thing is that you will change settings and have to learn new systems many times in your career. Some people aren't bogged down learning how to navigate practical real world things but many students, myself included, are more "book" people and can stand to benefit practicing that skill.

 

[ewax]

Practice presenting patients in front of the mirror...it helps a lot especially during the first few clerkships.

 

[Crayola227]

hmmm
upon reflection, this post
http://forums.studentdoctor.net/threads/things-to-do-to-shine-in-pgy-1.1188633/#post-17640862
while aimed at the new intern, has quite a bit that might help a new MS3

some of if you literally won't understand, some is way beyond where you need to be, but I think quite a bit will apply

buried in there I go into some nitty gritty of what it means to throw a resident under the bus

mantra for 3rd & 4th year: when you go to open your mouth to speak, if one option will make you appear smarter but the other will make you more likeable, go with more likeable every time

keep in mind in June the intern was only a 4th year student as of like yesterday
and that for them boards was almost 2 years ago, and there's a good chance 4th year a lot of their knowledge atrophied
you having come right off Step 1 have the opportunity to make them feel *really* stupid come pimp time so be sensitive
tread carefully around them, as though they are an insecure, overworked, starved carnival bear in a cage that is regularly beaten with sticks
believe me, everyone is far more clueless than they appear to be

there's a chance you know the EHR, hospital layout, system better than the interns, you could use that to your advantage
try to quickly wrap your mind around these things so you can lend these poor bastards a hand

and it's totally kiss assy but feel no shame bringing food to share with the team

 

[Gambler 101]

A lot of the behavioral/professional stuff has already been covered. I've just finished third year, and one of the biggest changes was the freedom to choose my own resources for studying. At the beginning of the year, I investigated all the books available for the clerkships. I wrote a "syllabus" with the different books plus any skills I wanted to master. For instance, on medicine I wanted to improve on EKGs, chest x-Ray, and CT. On surgery, it was describing wounds, dressing changes, suturing, etc. Having set goals and resources before each rotation took the guess work out of it. That plus a good attitude/being friendly made third year a breeze.


Sent from my iPhone using SDN mobile

 

[PL198]

All you have to do is not be socially inept. Seriously if you just show up on time (ie 5-10 min early), don't sit on your phone during lectures or similar and not skip stuff or leave before everyone else, you will easily be in top 50%. It's crazy how many people fail to do those 3 basic things.

 

[NickNaylor]

I've had the chance to work with medical students on general medicine wards, neurology wards, and the psychiatry inpatient unit. A lot of great stuff has been covered (@mimelim's post in particular is excellent) but I will rehash a few things that I've noticed that tend to set great students apart from good students. Note that while at my institution residents do not actually evaluate medical students, more times than not the attending will ask for our input on students. I have no idea to what degree they utilize that input, but just recognize that even if all of your evaluations are done by attendings, your residents may still get an indirect say in your ultimate grade. Read: don't be two-faced just because you think residents aren't evaluating you.

First, the most important things are basic, welcome-to-the-real-world stuff: show up every day, be on time, do not disappear, and do what you're told. Sometimes you may be asked to do "scut" - please understand that this work, despite the pejorative name, is extremely important to the functioning of the team. We residents have about a million things we need to do on a busy service, and unfortunately you, as a medical student, can't do much of it. The few things that you can do are immensely helpful. If one of your residents asks you to do something, do your best to figure out how to do it and get it done quickly. If you don't know how to do it, then let them know and ask for instructions. What I don't like it when I ask a student to do something and a couple of hours later it hasn't been done because they "didn't know what to do." I assure you that if you're able to do these things that may seem unimportant, you will be in the good graces of your team.

Be interested in what's going on. The reality is that you are very likely not going into whatever rotation you're doing at any one time. Unless you're pathologically crazy most people will not expect that you will be going into their field. That's fine. However, you are still expected to complete the clerkship and do your absolute best in the process. If I have a medical student going into [not this rotation], then I will do my best to tailor teaching and patients such that they will hopefully be interesting or useful to their future work, but not having an interest in a specialty is not a free pass to coast through the rotation. You don't need to be super goodie goodie and chomping at the bit to do every little thing ever, but approach the rotation as if you have something to learn or take away from the experience (protip: you do). It's a subtle but important shift in attitude that I can very easily pick up on, and it generally leaves a bad taste in my mouth when a student couldn't care less about what's going on. Even if the student does well, that attitude will ding my impression of them.

You should know your patients extremely well. If I'm covering 3-4 times as many patients as you, it looks bad if you don't understand what is generally going on with a patient and I have to answer all the questions on rounds about your patients. Sometimes there are things you will be out of the loop on - you can't help that. Your resident should do their best to update you with things that change, but again, we're busy and sometimes that goes by the wayside. However, you should know the results of recent tests/labs/other procedures, know what's planned for the day, and know what happened overnight at a minimum. This requires doing a quick perusal of the notes since the last time you saw them. Bonus protip: look at orders to see if the resident has put anything in so that you can talk about those things in your plan.

For presentations, it's ok to give an extremely thorough history and physical exam for the first couple of patients you present to show the attending that you know how to do a complete H&P, but after that, for the love of God, please start to make your presentations concise. Two weeks into a rotation, we don't need to hear every little normal finding on your physical exam. It's not helpful, and it eventually becomes annoying if an attending lets you ramble on as it's a huge waste of time. Figure out how to present things concisely. I was just on a general neuro service, so, for example, instead of listing every cranial nerve and describing what is effectively a normal exam, say something along the lines of "cranial nerves II-XII were tested and unremarkable." Congratulations, you have shortened a 3 minute portion of the presentation to 10 seconds. Again, it's fine to do a thorough presentation initially, but you will have to learn how to become quick and efficient, and you can start by doing that on your rotation. Take cues from your residents and what the attending seems to expect. If no one else is presenting a complete exam, then you probably shouldn't be either.

A general tip when getting new patients: spend time looking up the patient's history in the EMR. For example, if you see someone has a history of "CHF," then I'm going to expect that they've had a TTE (and will want to know what it showed), I will expect that they are on an ACE-I/ARB (and if not, then find out why), and I will want to know what previous interventions, if any, have been done (e.g., angiography, PCI, etc.). Same goes for COPD (want to know PFTs), T2DM (last A1c), and just about any chronic condition. Don't just take what is written in the previous/ER note for granted. You will be surprised that people have diagnoses for chronic conditions yet have never had any sort of diagnostic testing done in the past to support the diagnosis. You need to prove to yourself that they have these conditions. This will also make you look like a stud when you look up this information in addition to being helpful for, you know, treating the patient.

Whether you like it or not, your likeability as a student does play a role in our impressions of you. Someone that is enjoyable to be around in addition to doing all of the above is going to leave a better impression than someone who does well but is unpleasant to be around. That's just how it is. Do your best to try not to be annoying, and don't be afraid to be yourself on your rotation. Maybe be a little cautious the first few days to get the social lay of the land, but it's not required that you be a stiff with no personality throughout the whole rotation.

And finally, a general approach on attitude: pretend as if you're the resident taking care of the patient. You won't be able to put in orders, but pre-round on your patients on your own, present patients on your own, write your notes on your own and see how the approach of the resident/attending differs from yours and try and learn from the experience. IMO, that is the best way to learn. Sure, run things by the resident before rounds to make sure you're not thinking up things that are completely goofy, but do the initial intellectual legwork on your own before talking it over with a resident. Simply parroting what the other members of the team said without thinking about what's going on is not going to net you much education. You learn by doing just as much with taking care of patients as with procedures. Do your best to figure things out on your own and then talk with your resident or attending about why their plans differ from yours.

A note for the M4s: if you're doing a sub-I, you should be expecting to work and work hard. You are supposed to be functioning at the level of an intern. Yes, I know you're going into emergency medicine and you don't care about inpatient medicine and yes, I know you've already submitted your ROL so you're checked out, but don't be a complete slacker. I had the misfortune of working with a few M4s that were more than useless on their sub-Is because they "didn't care about rotations anymore. Protip: you probably don't want that to be one of the first things you tell me when I meet you.

 

[sloop]

I've had the chance to work with medical students on general medicine wards, neurology wards, and the psychiatry inpatient unit. A lot of great stuff has been covered (@mimelim's post in particular is excellent) but I will rehash a few things that I've noticed that tend to set great students apart from good students. Note that while at my institution residents do not actually evaluate medical students, more times than not the attending will ask for our input on students. I have no idea to what degree they utilize that input, but just recognize that even if all of your evaluations are done by attendings, your residents may still get an indirect say in your ultimate grade. Read: don't be two-faced just because you think residents aren't evaluating you.

First, the most important things are basic, welcome-to-the-real-world stuff: show up every day, be on time, do not disappear, and do what you're told. Sometimes you may be asked to do "scut" - please understand that this work, despite the pejorative name, is extremely important to the functioning of the team. We residents have about a million things we need to do on a busy service, and unfortunately you, as a medical student, can't do much of it. The few things that you can do are immensely helpful. If one of your residents asks you to do something, do your best to figure out how to do it and get it done quickly. If you don't know how to do it, then let them know and ask for instructions. What I don't like it when I ask a student to do something and a couple of hours later it hasn't been done because they "didn't know what to do." I assure you that if you're able to do these things that may seem unimportant, you will be in the good graces of your team.

Be interested in what's going on. The reality is that you are very likely not going into whatever rotation you're doing at any one time. Unless you're pathologically crazy most people will not expect that you will be going into their field. That's fine. However, you are still expected to complete the clerkship and do your absolute best in the process. If I have a medical student going into [not this rotation], then I will do my best to tailor teaching and patients such that they will hopefully be interesting or useful to their future work, but not having an interest in a specialty is not a free pass to coast through the rotation. You don't need to be super goodie goodie and chomping at the bit to do every little thing ever, but approach the rotation as if you have something to learn or take away from the experience (protip: you do). It's a subtle but important shift in attitude that I can very easily pick up on, and it generally leaves a bad taste in my mouth when a student couldn't care less about what's going on. Even if the student does well, that attitude will ding my impression of them.

You should know your patients extremely well. If I'm covering 3-4 times as many patients as you, it looks bad if you don't understand what is generally going on with a patient and I have to answer all the questions on rounds about your patients. Sometimes there are things you will be out of the loop on - you can't help that. Your resident should do their best to update you with things that change, but again, we're busy and sometimes that goes by the wayside. However, you should know the results of recent tests/labs/other procedures, know what's planned for the day, and know what happened overnight at a minimum. This requires doing a quick perusal of the notes since the last time you saw them. Bonus protip: look at orders to see if the resident has put anything in so that you can talk about those things in your plan.

For presentations, it's ok to give an extremely thorough history and physical exam for the first couple of patients you present to show the attending that you know how to do a complete H&P, but after that, for the love of God, please start to make your presentations concise. Two weeks into a rotation, we don't need to hear every little normal finding on your physical exam. It's not helpful, and it eventually becomes annoying if an attending lets you ramble on as it's a huge waste of time. Figure out how to present things concisely. I was just on a general neuro service, so, for example, instead of listing every cranial nerve and describing what is effectively a normal exam, say something along the lines of "cranial nerves II-XII were tested and unremarkable." Congratulations, you have shortened a 3 minute portion of the presentation to 10 seconds. Again, it's fine to do a thorough presentation initially, but you will have to learn how to become quick and efficient, and you can start by doing that on your rotation. Take cues from your residents and what the attending seems to expect. If no one else is presenting a complete exam, then you probably shouldn't be either.

A general tip when getting new patients: spend time looking up the patient's history in the EMR. For example, if you see someone has a history of "CHF," then I'm going to expect that they've had a TTE (and will want to know what it showed), I will expect that they are on an ACE-I/ARB (and if not, then find out why), and I will want to know what previous interventions, if any, have been done (e.g., angiography, PCI, etc.). Same goes for COPD (want to know PFTs), T2DM (last A1c), and just about any chronic condition. Don't just take what is written in the previous/ER note for granted. You will be surprised that people have diagnoses for chronic conditions yet have never had any sort of diagnostic testing done in the past to support the diagnosis. You need to prove to yourself that they have these conditions. This will also make you look like a stud when you look up this information in addition to being helpful for, you know, treating the patient.

Whether you like it or not, your likeability as a student does play a role in our impressions of you. Someone that is enjoyable to be around in addition to doing all of the above is going to leave a better impression than someone who does well but is unpleasant to be around. That's just how it is. Do your best to try not to be annoying, and don't be afraid to be yourself on your rotation. Maybe be a little cautious the first few days to get the social lay of the land, but it's not required that you be a stiff with no personality throughout the whole rotation.

And finally, a general approach on attitude: pretend as if you're the resident taking care of the patient. You won't be able to put in orders, but pre-round on your patients on your own, present patients on your own, write your notes on your own and see how the approach of the resident/attending differs from yours and try and learn from the experience. IMO, that is the best way to learn. Sure, run things by the resident before rounds to make sure you're not thinking up things that are completely goofy, but do the initial intellectual legwork on your own before talking it over with a resident. Simply parroting what the other members of the team said without thinking about what's going on is not going to net you much education. You learn by doing just as much with taking care of patients as with procedures. Do your best to figure things out on your own and then talk with your resident or attending about why their plans differ from yours.

A note for the M4s: if you're doing a sub-I, you should be expecting to work and work hard. You are supposed to be functioning at the level of an intern. Yes, I know you're going into emergency medicine and you don't care about inpatient medicine and yes, I know you've already submitted your ROL so you're checked out, but don't be a complete slacker. I had the misfortune of working with a few M4s that were more than useless on their sub-Is because they "didn't care about rotations anymore. Protip: you probably don't want that to be one of the first things you tell me when I meet you.

This is a good post. The only thing I'll say is that all of the things we can advise are only guidelines and there are always exceptions. You will figure this out better by the end of third year. Even the "don't disappear" thing has some specific exceptions.

Case in point: earlier in the year, I was on a rotation where I was essentially on a 24 hour call and my resident was basically on 12 hour call (complicated situation, but this was the gist of it). My resident was aware of this, but I think forgot about it. Nothing was going on by like 1 in the morning but he never said I could go try to catch some sleep. I didn't say anything and just powered through, staying up all night Friday into Saturday. Again, complicated situation but I then went home had 24 hours off, then had 12 hour call on Sunday and had to start the regular week again on Monday. I was destroyed. It worked out okay in the end but it was unnecessarily exhausting.

Fast forward to a few weeks ago and I was on 24 hour call with another student while residents were on night float. Nobody explicitly told us to go to bed but the other student basically said they were going to lie down for a bit. I stayed for another hour or so because nothing was going on and the residents were just goofing around, but then I headed to the call rooms. We had pagers (automatically paged for important stuff, not paged by residents) though so we wouldn't miss anything. It was a much better experience. I don't think anybody was judging us. I guess I kind of "disappeared" but it was fine.

Likewise, in truth, some residents kind of suck and want students to disappear. You should probably just do this rather than bother them.

I will also say that as much as you want to be on your best behavior, not every misstep will be a disaster. If you do something in poor form, own up to it quickly and apologize. On one of my rotations I was being scutted out all day every day by one terrible intern. I barely had time to learn anything about my patients because I was doing social work crap all day. Literally the last day of the rotation I informed him that I couldn't get the information from one hospital for a patient because when I called them and faxed the information, they told me that the patient had never been to their institution and they had no record of him, but that I got the information from the other hospitals he visited. The resident then said something along the lines of "This is unacceptable. You're supposed to be able to figure these things out. I don't understand why you can't. When you hit a roadblock, you have to find a solution not throw up your arms and make excuses why you couldn't complete the task. Now, go find a solution." I snapped at that resident and basically told him "whatever, man. The patient wasn't there so what do you want me to do about it? I can't change reality. If you still don't believe me, go try for yourself" and walked away. Obviously I don't recommend this approach, but I later apologized to him and smoothed things over. It did not affect my evaluations at all.

 

[NickNaylor]

This is a good post. The only thing I'll say is that all of the things we can advise are only guidelines and there are always exceptions. You will figure this out better by the end of third year. Even the "don't disappear" thing has some specific exceptions.

Case in point: earlier in the year, I was on a rotation where I was essentially on a 24 hour call and my resident was basically on 12 hour call (complicated situation, but this was the gist of it). My resident was aware of this, but I think forgot about it. Nothing was going on by like 1 in the morning but he never said I could go try to catch some sleep. I didn't say anything and just powered through, staying up all night Friday into Saturday. Again, complicated situation but I then went home had 24 hours off, then had 12 hour call on Sunday and had to start the regular week again on Monday. I was destroyed. It worked out okay in the end but it was unnecessarily exhausting.

Fast forward to a few weeks ago and I was on 24 hour call with another student while residents were on night float. Nobody explicitly told us to go to bed but the other student basically said they were going to lie down for a bit. I stayed for another hour or so because nothing was going on and the residents were just goofing around, but then I headed to the call rooms. We had pagers (automatically paged for important stuff, not paged by residents) though so we wouldn't miss anything. It was a much better experience. I don't think anybody was judging us. I guess I kind of "disappeared" but it was fine.

Likewise, in truth, some residents kind of suck and want students to disappear. You should probably just do this rather than bother them.

I will also say that as much as you want to be on your best behavior, not every misstep will be a disaster. If you do something in poor form, own up to it quickly and apologize. On one of my rotations I was being scutted out all day every day by one terrible intern. I barely had time to learn anything about my patients because I was doing social work crap all day. Literally the last day of the rotation I informed him that I couldn't get the information from one hospital for a patient because when I called them and faxed the information, they told me that the patient had never been to their institution and they had no record of him, but that I got the information from the other hospitals he visited. The resident then said something along the lines of "This is unacceptable. You're supposed to be able to figure these things out. I don't understand why you can't. When you hit a roadblock, you have to find a solution not throw up your arms and make excuses why you couldn't complete the task. Now, go find a solution." I snapped at that resident and basically told him "whatever, man. The patient wasn't there so what do you want me to do about it? I can't change reality. If you still don't believe me, go try for yourself" and walked away. Obviously I don't recommend this approach, but I later apologized to him and smoothed things over. It did not affect my evaluations at all.

Sure, there are exceptions to everything, but I stand by the above as a general rule. Of course, part of the job of medical student is to figure out when those things don't apply and, in their place, figure out what does apply.

 

[sloop]

Sure, there are exceptions to everything, but I stand by the above as a general rule. Of course, part of the job of medical student is to figure out when those things don't apply and, in their place, figure out what does apply.

Yeah, agree with everything you wrote. That was basically what I was trying to say in my original post.

 

[WinslowPringle]

-Show up. And if you don't show up, let someone on the team know about it. For example, don't be like the guy who decided to just not come in one day thinking we had no cases. We did have cases...
-Don't pimp your resident in front of the attendings. Don't pimp your fellow med students in front of residents/attendings.
-If you're in the OR and it's blue and you aren't sterile, don't touch it. If you're sterile, don't touch things that aren't the patient or blue. For example, don't adjust your glasses with sterile gloves and then touch the prepped and draped patient.....
-Don't argue when you're wrong. I mean, it's one thing to be right and state that diplomatically but for the love of God don't persevere when you're dead wrong and you've been told so. Be able to admit fault.
-If the resident says "Come here, let's put in some orders" do it and don't say 'Oh, that's ok, I have to help move the patient.' You're paying 50k/year to learn to be a doctor, and not push patients from bed to bed.
-Don't page the resident at home at 11pm to tell them that you are now off call.
-Don't decide to not round on your patients just because it's early.

 

[cbrons]

My advice is to try as much as possible to maintain some sort of positive optimistic outlook despite the fact that 3rd year is essentially 95% a complete and utter waste of your time where you will not learn a single useful thing.

Be grateful for those residents and attendings that actually let you give presentations, write notes, put in orders, etc. because most of the time you will be shadowing them (which should actually be cause for the LCME to put a program on probation, but alas they don't seem to think it matters whether or not med students pay 40k/year to shadow like a pre-med).

You can be proactive if you want, but it won't always make you look good. For example, calling for medical records for a patient just admitted.

Don't spend 90 minutes in a patient's room doing your H&P but come out not knowing anything of actual pertinence. A corollary to that would be, know the basic questions you must ask for a variety of basic problems.

Example: There was a girl on one of my rotations who really liked to chat with patients and let them go on all manner of tangents and side stories. One patient was there because she had a syncopal episode. After 2 hours in the patients room, the attending asked her very basic things like, "Has this ever happened to her before?" and "Did she regain consciousness right away or was it gradual?" and "Does she have a family history of sudden cardiac death or unexplained sudden death?" These are extremely basic questions in the workup of syncope, yet she didn't know a single one. She was a young female student, so the attending probably didn't hold it against her, but if it was me or another male who came out looking this stupid, you know it would've impacted our grade negatively.

Speaking of knowing the right questions, this book I found extremely helpful.
It has sample write-ups of basic problems in internal medicine, which you can use to extrapolate questions you should ask for every patient and then incorporate it into your presentation.
My presentations I have been told were excellent because I answered all of the questions the attending wanted to know just by incorporating it into my presentation.

Don't make the residents look bad ever. Even if they are a complete idiot, do not correct them or question them especially in front of their attending. Should be common sense for any normal human being.

Just volunteer to do the damn scutwork. Go pick up after visit summaries from printers, carry labs down, make phone calls for medical records, etc. Yes it is not technically your job, but neither is shadowing, and they're going to make you do that anyway. Might as well walk around a little or do something to help break the monotony because its not like theyre going to let you do anything better in most cases.

Go out of your way to be pleasant and friendly to the nurses and office staff.

Recognize that despite being "on the wards" the vast majority of your learning, especially in those rotations where they don't let you do anything, will come from textbooks or outside study resources (just like first and second year).

Don't be a lying scumbag when the school asks you to evaluate the rotation. If all you did was shadow, then you should very bluntly state how much of a waste of time the rotation was. The evals are confidential, so don't try to sugar coat it. You screw over the future M3s by saying a rotation was great and you learned a lot when it was very obviously a complete and utter waste of time.
Likewise, if you actually got a preceptor who let you contribute to patient care, you should sing their praises like they are the best teacher of medicine since Bill Osler. Even if they were incredibly rude to you and ridiculed you, still talk them up and rate them high. Do not be like the female med students in this generation who take it personally when someone is "mean" to them. You shouldn't care if they humiliate you in front of a crowd of people, as long as they are actually letting you DO something and improve at the skills necessary of a physician. That experience is worth 100 rotations where all you do is shadow and go through online CLIPP cases.

 

[Mr Roboto]

... Example: There was a girl on one of my rotations who really liked to chat with patients and let them go on all manner of tangents and side stories. ... She was a young female student, so the attending probably didn't hold it against her, but if it was me or another male who came out looking this stupid, you know it would've impacted our grade negatively.

... Do not be like the female med students in this generation who take it personally when someone is "mean" to them. ...

Classy, bro.

 

[NickNaylor]

Classy, bro.

Frankly there is a grain of truth to it. There are a couple of residents in my class that claim some attendings are "sexist" because the attendings weren't buddy buddy with them. There are also attendings that the same small group of residents complain about and yet I haven't had any problems with them when I've worked with them.

I think it is a problem with out generation that people have a minimal ability to accept critique without taking it personally. Not limited to women IMO though it does seem to be more common.

 

[cbrons]

Classy, bro.

Who r u?