Away Rotations: Excelling

[neutropeniaboy]

Excelling During an Away Rotation

For several years now I have experienced the pleasure and agony of working with medical students who are doing their sub-internships, audition rotations, acting internships or away rotations in otolaryngology. The reasons behind doing such rotations are always quite variable when students are queried. Because of the wide variety of motivations, many students may not feel like they have a solid grasp on what the audition rotation is, what they need to do or what it is that they need to be seeking.

Recently I posted some musings on what I thought medical students should be doing in order to land an otolaryngology residency (http://forums.studentdoctor.net/showthread.php?t=981343). Although heavily biased, I suggest you take a look at the thread if you haven’t already.

This post, however, is designed specifically for 4th year medical students who are doing rotations. Long have I posted that away rotations are necessary evils. I say this because for students, they are in many cases the only way to get exposure to the field and to determine if a particular institution aptly suits their needs or to confirm that otolaryngology is what they want to do. I say that these rotations are pure evil because so many students do not do well on them. In other words, it becomes apparent in so many ways why those students should be ranked low or not ranked at all.

I’m not here to validate the reasons underlying the desire or need to do these rotations, but let’s look at what I consider the characteristics that make or break a student rotation. Take a moment to read this brief article (http://archotol.jamanetwork.com/article.aspx?articleid=1729117) that comes directly from the August 2013 issue of JAMA Otolaryngology – Head & Neck Surgery (formerly Archives of Otolaryngology). The subject of the article surrounds cutting through the plethora of questionable data to arrive at what most likely is the key to selecting the best resident possible: possessing a solid character. The article shows an excerpt from the “Graduate Training for General Surgery and the Surgical Subspecialties” printed in 1939:

1.Character. In its broadest interpretations, character involves many distinct qualities, but so far as the surgeon is concerned it may be summarized in one word – Honesty. Character embraces ethics, conscientiousness, judgment, industry, and all other elements which make up the background of a surgeon. Honesty must be evident in action, in example, in utterances, in writings, and in all contacts with patients, confreres, and all others who are allied to the practice of surgery. Honesty demands that the welfare of the patient shall be ever foremost. Honesty, coupled with surgical judgment, learning, and technical skill, assures a proper balance in diagnostic and operative procedures. Therefore, the primary qualification in the selection of applicants is evidence of high character.​

This really struck a chord with me since so long ago – in an era when residents were truly residents of the hospital – the most critical possession of the ideal candidate was an intangible quality and something that could not be achieved by reading a book, by watching videos or by practicing in a lab. To me, character has everything to do with upbringing, respect, ethic and virtue.
Plainly, if you fail to possess this “character” or “honesty,” I can assure you that every attempt to audition yourself will fail, and I have seen many students fail famously in the process. Others fail because they confuse character with ambition or think that capacity exceeds character.

Well, although important, capacity never exceeds character.

THOUGHTS ON GETTING IT RIGHT

Normalcy: One of the points I made in my previous post, is that the good student candidate is a normal person. Do not confuse the word “normal” with average. Otolaryngology residents are anything but “average.” It doesn’t take long to look at the list of achievements to know that the average otolaryngology resident isn’t average when comparing him to the norm. Those are achievements. Character is not an achievement, and neither is a normal disposition. Being a normal person doesn’t mean you can’t be quiet and reserved; being a normal person doesn’t mean you have to be outgoing and make everyone around you laugh. Of course you want to impress your attendings and residents (why show off your wares if the purpose isn’t to toot your own horn in some way?), but so many people find it difficult to shine without distracting attention from all else that is important specifically to highlight their own interests.

Common Sense: This is not unrelated to the quality of being normal. I will tell you that the student candidate who will be on my team is the one with a Step I score of 230 and has good judgment and a practical sense, not the student who has a Step I score of 260 and can’t translate knowledge into clinical practice. Being smart doesn’t make you a good clinician; it helps, but it doesn’t make.

Respect: Is it not expected that one should look another in the eye or shake hands? Is it typical to introduce one’s self when entering a room when that individual is new or unexpected? Every great student that I’ve encountered has walked up to me, reached out his hand (when I’m not scrubbed, of course) and has introduced himself or herself. They’ve told me who they are, where they are from, and offered a succinct and insightful thought on why they are here and what they have hoped to accomplish while with us as they visit. (I did not say “me” intentionally, because I’m one part of a team of physicians, nurses and staff.) Every good student has asked me early in the rotation what I expect of him or her when specifically working with me. After this, it becomes clear what the student should or should not be doing, and students spend less time wondering and more time acting. This is demonstrating respect on one level, and most students will rise to this level. However, it’s after that where many students fall short. There are residents. There are nurses. There are ancillary staff. There are patients. There are medical professionals in other disciplines. I’m sure you have heard the expression “all roads lead to Rome.” Never forget: “all that you do gets back to the attending.” Students who excel have respected the residents, nurses and staff. Students who excel respect the patients. Over the years, this failure has played out in so many ways. A few examples of epic failures:

• The attending has finished all surgery/clinic for the day. The resident still has much to do. The student either leaves unannounced (apparently feeling that there was no more learning to be accomplished) or emphatically states to the resident the s/he is seeking out another attending for a learning opportunity. The resident leaves to do work, miffed, but ultimately unhindered by the burden of a disinterested student. I’ve seen this and heard about this many times. It does not please me in the slightest to learn that a student on a particular service no longer is interested in helping out the service.
• I’ve been personal witness to (and have heard via complaints) students disrespecting nurses. I’ve seen this in the clinic and I’ve seen this in the OR. I wonder if this behavior comes out in the midst of trying to move things along to impress the attending or resident, to get things done, or to show that the student is not a push over. I find it unbecoming of anyone on any level to act this way, and frankly, as a student, you are the last in line to be given permission to act this way if such a wish were granted. On the flip side of things, I will actively defend a student who is purposely being ridden by a nurse simply because s/he is a medical student. It works both ways for me. If you disrespect my team, in all likelihood, you’ll find yourself at the bottom of the list if on the list at all.
• The residency coordinator (the non-MD, i.e. secretary) often has a difficult job of managing the residents and dealing with rotating students. Often this involves a lot of paperwork, completing ACGME-required evaluations, helping with licenses, etc. There is very little room or tolerance for a demanding or annoying student. Before each interview season ends, I pull our residency coordinator aside and ask for the “inside” on all the students. It’s amazing to me that students permit themselves to bark orders and demands about when and where things get done.
• Sexual discrimination/Racial discrimination. I’m not a card carrying member of the ACLU, NAACP, NOW or anything other than the AAOHNS; however, you simply cannot be a part of my team if you act racist or sexist. We live in a modern society in which so many valuable team members are people of different races, creeds and genders. Joking about sex, sexual preference or race is unacceptable. I’ve seen students openly make disparaging comments about patients right in front of me: from a student saying, “that’s how they settle their differences” when discussing a bullet wound injury to the temporal bone (African American patient) to homosexual jokes at an after party around another student who was gay to stating that their needed to be fewer women in surgery because women would have trouble having and raising children.

Auditioning: You are being watched the entire time. You are on a 4 week-long interview. From the moment you arrive on day one to the very second you leave on day 30. Where you are, what you are doing, how you are doing and what you intend to do are being scrutinized. Sound crazy? It’s not. If you’re going to spend 5 years with me, I better be damned sure you are the type of person who possesses the character and work ethic that is necessary for this field. The very best students have always shown up before the residents show up and have something available to help the resident or residents accomplish what they need to do before the day starts. Good students will have pre-rounded on patients in the hospital. If the resident doesn’t want that or need that, it’s no problem. See for yourself and get in the habit of being what residents are day in and day out: working machines. All good students share the load. That means writing progress notes, carrying supplies, getting x-rays, helping clean instruments, etc. Yes, this sort of activity dulls the mind and makes one feel as though they are being taken advantage of. If you find a big complaint in this, you will find being an actual intern unbearable. Maybe residency is not for you then. Now, if you are being treated like a mule and the resident is following you around with a cup of coffee, then you have a right to be upset. But, don’t forget what you are doing: sub-internship (sub means beneath), acting internship, audition rotation. Don’t forget your place, and that’s at the end of the line. In the operating room, a situation may arise when the junior resident is operating and a page comes in for the resident to deal with a non-emergent situation. It is entirely reasonable for the resident to ask the sub-I to check it out. In some instances, this means breaking scrub and leaving the OR. If you are asked to do it, the good student replies, “ no problem; I’ll check it out and get back to you ASAP.” The questionable student rolls his or her eyes or pouts on the way out the door or tries to find some endearing reason why it’s more valuable to watch the surgery or continue to see patients in clinic. I usually say nothing during these interactions, because I believe it is up to the resident to sort out this interaction. However, I remember those students and the choices they make well. All great students have asked if they can take overnight call. I hear some institutions prohibit this, and this will be make clear to you when you get the policies and procedures lecture/manual during your rotation. If it isn’t specifically prohibited, ask to take call. Do not demand it, because maybe the residents don’t want you to. I can’t imagine a resident who wouldn’t love to have you write a note in the middle of the night or help with working up a patient – as long as you don’t slow the resident down in the middle of the night. When the day is done, the good student knows he is not done. No matter what the situation, students are the last to go. Once the attending is done, the residents usually have some work to do. As a student, you should help your team – not seek another team. When the resident is done, it is prudent to ask if there is anything the resident wants or needs in preparation for the next day. If there is nothing – there never is nothing – then it is likely that you can go or see what some other attending/service is doing. If the residents say you can go, I suggest you either go and prepare for tomorrow or find something else that is going on in the O.R. or in the clinic. So, you are the first in and the last out.

Preparedness: No good resident or student has ever shown up to my O.R. and asked what we are doing today unless at the last minute someone was asked to “staff” my OR. If you don’t know what I’m doing in the OR, I’d rather you leave and let me operate in peace, as I am sure my case will run much faster, much more smoothly and with better outcomes. It is not acceptable for students to show up in the morning and ask the resident what they are doing that day. Good students will know on Monday what’s going on Friday. Since on Tuesday the student on the otology service knew I was doing 3 tympanoplasties on Wednesday, the student was fully prepared for these surgeries having read the night before. The student read the chart, which is especially easy given most academic centers now have EMR, and the student read some text that highlighted the relevant anatomy and the procedure. Since when was it acceptable for a rotating student on a surgical rotation to not understand basic anatomy? Isn’t this your chosen field? Why do you not already have some baseline understanding of H&N anatomy that is more advanced than your counterpart who is going into urology? I look back on my medical school career, and I often had to remind myself to put down the ENT books when I was on my medicine rotation. Why was it that I read about renal failure for all of 2 seconds and when it came to hypothyroidism I had to read all the latest journals on thyroid disease, thyroid surgery and thyroid anatomy? This is supposed to be what you love and want to do. Why must you be convinced you need to prepare for the next day? Good students have also practiced some basic surgical skills by this time in their careers. If you haven’t practiced tying knots on your lab coat, the back of someone’s chair or sutured up a bunch of hot dogs, you should really think about acquiring that skill as soon as possible. On occasion it is difficult to get real experience doing this, and that is understandable. I’m also interested in how you get coached by me and the resident and how you improve while on your rotation. I’ll work with a resident who has no skills as long as I know they have a high likelihood of being trainable. Most residents are trainable from a technical standpoint; most residents who lack character and a solid work ethic never gain it through residency, however.

Odds and Ends: Don’t ever schedule Step II or any other exam during an ENT rotation. Don’t ever pout because a resident says you can’t close or because a resident has asked you to stop so he or she can take over. If they don’t want you to close, it’s because the resident needs experience, the resident knows the attending wants it that way, the resident feels rushed, or the resident simply doesn’t like the way you do it. All are acceptable reasons to take over and force you to watch in my opinion. All eyes are watching how you take this disappointment. We know it’s hard when you want to do so much, but your time will come; now isn’t that time. In the past 7 years, I have come across two students who were “the bomb.” I remember them keenly. One of them “got away” and one of them is now my partner. And that was just in my eyes. What I admired about these two was that they did not perceive themselves as walking on water, even though in my eyes I would have argued that they did. You may be the one who walks on water, but I guarantee that most of you, like myself for sure, do not. Yet some of you think you do, and this will get you nowhere in life, let alone a surgical program. Be helpful to your fellow student – they’re trying to get everything out of the rotation that you are; when you actively sabotage their efforts, this will eventually be noticed, and the outcome will not be in your favor. Trust me.

EPILOGUE

The above just represents a train of thought as I begin to close out the peak of our audition time of the year. Maybe some of you will find it helpful if you have yet to do a rotation. Maybe some of you will pick up on something you did and have to find ways to rectify that. Others still will probably disagree with my musings, but that's what forums are for: discussion.

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[neutropeniaboy]

Reserved

 

[nacholibre]

This is all too late, because I just finished my sub-I, but I would still like to know what you think about this situation since I still have another month here at my institution.

This month has been...miserable (in some ways)! I realize that most will hear this and think, "well that's probably your fault" but allow me to explain.

Introduction: I don't think that I am a lazy, annoying, etc student, every eval I have received over the course of 3rd year was very positive, I had at least 1 attending approach me on every rotation and offer to write letters of rec. Residents have consistently praised my willingness and ability to help out...I tell you this just as a starting point.

My ENT rotations (both 3rd year elective and now sub-I) have essentially felt like 30 days of shadowing and trying not to annoy the residents. I showed up early the first day of every service I was on to pre-round I was told not to do that because they would just have to look at the numbers anyways (mind you this was before they had even looked at my work), I wrote notes on at least 1/3 of the patients, but was consistently told not to, when I asked if I could just do it to get in the habit, I was told that it was inconvenient because then they would have to sign my notes. I tried to return pages, but 90% of the time was told not to worry about, it would be easier for them to take care of it later. And this atmosphere was there the entire time. It even got to the point where they told the students we didn't have to come round, and acted annoyed when we did come in. WTF????

How does one "shine" in this situation?? Is this a giant red flag about my program??

 

[neutropeniaboy]

If this was an away rotation, I would say that this is a red flag, unless the residents seem happy, get along well with each other, get a well rounded experience and the attendings seem competent.

They may just find it easier for you to shadow and aren't interested in that level of involvement.

nb

This is all too late, because I just finished my sub-I, but I would still like to know what you think about this situation since I still have another month here at my institution.

This month has been...miserable (in some ways)! I realize that most will hear this and think, "well that's probably your fault" but allow me to explain.

Introduction: I don't think that I am a lazy, annoying, etc student, every eval I have received over the course of 3rd year was very positive, I had at least 1 attending approach me on every rotation and offer to write letters of rec. Residents have consistently praised my willingness and ability to help out...I tell you this just as a starting point.

My ENT rotations (both 3rd year elective and now sub-I) have essentially felt like 30 days of shadowing and trying not to annoy the residents. I showed up early the first day of every service I was on to pre-round I was told not to do that because they would just have to look at the numbers anyways (mind you this was before they had even looked at my work), I wrote notes on at least 1/3 of the patients, but was consistently told not to, when I asked if I could just do it to get in the habit, I was told that it was inconvenient because then they would have to sign my notes. I tried to return pages, but 90% of the time was told not to worry about, it would be easier for them to take care of it later. And this atmosphere was there the entire time. It even got to the point where they told the students we didn't have to come round, and acted annoyed when we did come in. WTF????

How does one "shine" in this situation?? Is this a giant red flag about my program??

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[thinkorswim]

As a current resident and someone once in your situation, as a visiting medical student, I can remember feeling similar on my away rotations and not being given the chance to be helpful and show my work ethic. Being on the other side of that now has helped me understand why. That said, I do encourage our rotating students to do as much as possible when we have the time (e.g. workup a consult, follow up on labs or studies, pull drains or change dressings, get me coffee, etc.) and I greatly appreciate their help.

But at the end of the day, some things really are just easier and more time efficient for a resident to do. This is especially apparent when everything is documented in an EMR, which isn't at all designed with students/residents in mind and has frankly blunted medical education. It gets even more confusing in clinic where we have had issues with even residents writing notes for attendings. I can rant all day about EMRs and how asinine some of them are, but that's a topic for another time.

With regards to answering pages, you probably shouldn't even bother. It will invariably be something only a resident can and should deal with (e.g. consult, nursing about an inpatient, pharmacy about medication orders, etc.). Sure, a student can call back and get the information, but it's likely they will not be able to relay the entire information correctly or will forget to ask a certain question and have a resident call back again. It's much easier for a resident to answer the page.

I'm not sure what to make of the whole rounding situation you describe. Perhaps the team rounds quickly on a lot of patients and medical student presentations/questions just slow them down. When our census blows up on certain days and we have to see upwards of 10 patients in a morning, discharge a couple, and then pre-op our patients for the day before the OR starts, the last thing I want to do is listen to a medical student present a patient. All I want to hear is pertinent information, drain output, and discharge planning on most patients.

My ENT rotations (both 3rd year elective and now sub-I) have essentially felt like 30 days of shadowing and trying not to annoy the residents. I showed up early the first day of every service I was on to pre-round I was told not to do that because they would just have to look at the numbers anyways (mind you this was before they had even looked at my work), I wrote notes on at least 1/3 of the patients, but was consistently told not to, when I asked if I could just do it to get in the habit, I was told that it was inconvenient because then they would have to sign my notes. I tried to return pages, but 90% of the time was told not to worry about, it would be easier for them to take care of it later. And this atmosphere was there the entire time. It even got to the point where they told the students we didn't have to come round, and acted annoyed when we did come in. WTF????

 

[Alvarez13]

As a current resident and someone once in your situation, as a visiting medical student, I can remember feeling similar on my away rotations and not being given the chance to be helpful and show my work ethic. Being on the other side of that now has helped me understand why. That said, I do encourage our rotating students to do as much as possible when we have the time (e.g. workup a consult, follow up on labs or studies, pull drains or change dressings, get me coffee, etc.) and I greatly appreciate their help.

But at the end of the day, some things really are just easier and more time efficient for a resident to do. This is especially apparent when everything is documented in an EMR, which isn't at all designed with students/residents in mind and has frankly blunted medical education. It gets even more confusing in clinic where we have had issues with even residents writing notes for attendings. I can rant all day about EMRs and how asinine some of them are, but that's a topic for another time.

With regards to answering pages, you probably shouldn't even bother. It will invariably be something only a resident can and should deal with (e.g. consult, nursing about an inpatient, pharmacy about medication orders, etc.). Sure, a student can call back and get the information, but it's likely they will not be able to relay the entire information correctly or will forget to ask a certain question and have a resident call back again. It's much easier for a resident to answer the page.

I'm not sure what to make of the whole rounding situation you describe. Perhaps the team rounds quickly on a lot of patients and medical student presentations/questions just slow them down. When our census blows up on certain days and we have to see upwards of 10 patients in a morning, discharge a couple, and then pre-op our patients for the day before the OR starts, the last thing I want to do is listen to a medical student present a patient. All I want to hear is pertinent information, drain output, and discharge planning on most patients.

This is what I love about ENT. We usually had around 5 and 10 was a lot! On peds surgery we had 30-50 on the list and tried to round on most of them.

To the OP, I'm in the same situation at my program with EMR. My favorite resident allowed me to sign on under him once and write the note, discuss the plan, and put in all the orders, with him behind me the whole time watching. One of the best learning experiences I had. However, that was rare and we're technically not allowed to type anything in the record or we can be dismissed and the resident fired. Sucks.

The way I tried to stick out was just to keep asking questions and ask to do everything in the OR. I always asked put in foleys, IVs, prep, suture to close and finally talked one attd into letting me take a tonsil out. They liked that I was excited about that and was always busy. That and I constantly looked out for the scrub techs and nurses (got supplies, helped ppl gown up, cleaned up the room).

 

[OtoHNS]

I agree that EMRs and computerized order entry have sabotaged much of the potential usefulness of medical students to the team. Your notes no longer count and you can't order anything. Also, the labs, radiology results, and vitals/drain outputs that you could obtain are now easier for residents to gather from the EMR on their own.

Forget about answering pages, no resident is going to let you do that. No offense, but it's pretty much guaranteed that you'll screw it up and cause them more work than just answering it themselves.

Focus on doing whatever you can to help. If you concentrate on menial tasks like cutting suture, sucking smoke, and retracting, and do them well, the opportunity may come to help close or do some bovieing.

Ultimately, your attitude and work ethic are what matter most and what will get you opportunities to do stuff. When I was a resident, I always went out of my way to teach students who were clearly interested and didn't complain. We realize that shadowing 100% of the time gets boring. Complaining and demanding isn't going to get you anywhere though. Wait for your chance patiently and you'll probably get it.

 

[neutropeniaboy]

Ultimately, your attitude and work ethic are what matter most and what will get you opportunities to do stuff. When I was a resident, I always went out of my way to teach students who were clearly interested and didn't complain. We realize that shadowing 100% of the time gets boring. Complaining and demanding isn't going to get you anywhere though. Wait for your chance patiently and you'll probably get it.

^This

 

[DrBodacious]

Focus on doing whatever you can to help. If you concentrate on menial tasks like cutting suture, sucking smoke, and retracting, and do them well, the opportunity may come to help close or do some bovieing.

Great advice in this thread so far.

I will say this past year as a chief, one of the 4th years was the best person I've ever seen at cutting suture. This is including my fellow residents and attendings. I am not sure if he practiced a lot at what he knew he would be doing or if he just had really good hands. I let the attending know, and made this known to all the faculty at the ranking meeting on interview day. He had made a lot of good impressions, in general, and he matched at our program.

If you are really good at doing subcuticular closures from closing hernia incisions, that is great, but you might not get to do it on the thyroid on head and neck. This can be from concerns about the neck incision, time constraints, or because the attending wants the resident to get the experience.

Just do what you are able to do well. There are opportunities for making good impressions, and avoid making bad ones.
I am surprised how many "tid bits" of valuable information I have retained from my fourth year ENT rotations. Rembering how an attending explained things to patients in clinic, etc. If you just shadow and soak up everything going on around you, you will get a lot out of it, you just may not realize it at the time.

 

[VisionaryTics]

I will say this past year as a chief, one of the 4th years was the best person I've ever seen at cutting suture. This is including my fellow residents and attendings. I am not sure if he practiced a lot at what he knew he would be doing or if he just had really good hands. I let the attending know, and made this known to all the faculty at the ranking meeting on interview day. He had made a lot of good impressions, in general, and he matched at our program.

How did he cut suture so well that you said, "This guy is on a new plane of suture cutting. Our program needs to snatch him up before he takes his suture-cutting talent elsewhere" ?

 

[Kahreek]

How did he cut suture so well that you said, "This guy is on a new plane of suture cutting. Our programs needs to snatch him up before he takes his talent elsewhere" ?

aaha, i ask the same 👍

 

[DrBodacious]

How did he cut suture so well that you said, "This guy is on a new plane of suture cutting. Our programs needs to snatch him up before he takes his talent elsewhere" ?

I am not trolling. He could just sort of nonchalantly fling his hand in there from a bad position and cut the perfect length in a blink of an eye. I thought he was getting lucky at first, but no. Mad suture - cutting skills.

 

[JP2740]

I have my 3rd year elective in a couple months in ENT. Do you think this pretty much applies the same to that? And I haven't had my surgery rotation yet, any advice for learning some useful things prior to if possible that might help my cause? I've heard they're very understanding that I won't be an expert at anything as basically just starting 3rd year and the rotation goes very well.

 

[neutropeniaboy]

3rd year students are welcome to come to my OR. Unlike 4th year students, and 3rf year who shows interest and isn't annoying gets treated well.

In would read ENT Secrets, and if you can answer basic questions, you'll be golden.

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[armybound]

So much great information for rotators. As an intern, I'm getting to see our first round of rotators, and this advice would have gone a long way for a few of them.

Character's huge. Work ethic is huge. We want to know that you'll make a good part of our team. That doesn't mean you have to have all of the same interests as us and entertain us all of the time, but if you're annoyingly arrogant, we don't care how smart you are or how hard you work. If you complain that your first two weeks consisted of too many hours / too much time in clinic / too many didactics, you might not be the kind of person we're looking for, since you'll be spending 5 years doing the same thing day in and day out.

I personally like seeing a 4th year who is comfortable letting someone else learn in the OR, even if it costs them an opportunity to do something. If you're willing to let the 3rd year struggle with their first subcuticular as you walk them through it without being told to, I think pretty highly of you. As long as you're teaching them how to do it correctly..

 

[socrates89]

great advice

 

[ThoracicGuy]

Excelling During an Away Rotation

For several years now I have experienced the pleasure and agony of working with medical students who are doing their sub-internships, audition rotations, acting internships or away rotations in otolaryngology. The reasons behind doing such rotations are always quite variable when students are queried. Because of the wide variety of motivations, many students may not feel like they have a solid grasp on what the audition rotation is, what they need to do or what it is that they need to be seeking.

This whole post should be required reading for all visiting students in any surgical area.

 

[Apollyon]

If you just shadow and soak up everything going on around you, you will get a lot out of it, you just may not realize it at the time.

First thing of which I thought:

[YOUTUBE]Bg21M2zwG9Q[/YOUTUBE]

 

[koojo]

Excellent write up.

 

[medstylee]

Some great advice on here that I wish I had when I was a student.

I rotated (and matched) at a program that has a very hands-off rotation. I definitely understand the frustration of going through an entire rotation, trying your best, and still not having any clue how well you did. The key is to figure out what you can do early on and just do your best at that. Sounds like common sense - easier said than done. Just remember that it's the beginning of the year and everyone is new at their roles - the juniors are new juniors, the seniors are new seniors, etc. Residents are still trying to parse out what their responsibilities/capabilities are at that point, so it can sometimes be a little overwhelming to have a student or multiple students thrown into the mix. If you are getting scolded for doing things like writing notes, getting numbers, pre-rounding, then you should be cautious about that program, or at least the residents you are working with. Even so, you have plenty of time to evaluate the program. Just because the rotation for students is hands-off might not mean the program isn't good. Pay attention to how the attendings treat the residents; how the residents treat one another - do people get along, is it a collegial environment; is there good mentorship.

I've seen a few years of rotators now and there have been a lot of "good" rotators, a few horrible rotators and a small handful (maybe 3) of "awesome" rotators. The very best rotator did what I said above - s/he spent the first two days figuring out what we expected and then just rolled with it. S/he wrote all of the pre-op H&P's the night before (way above and beyond), but we let him/her do it after we realized it wasn't keeping him/her there till all hours (this person was very efficient). And, they were excellent notes. Just little things like writing "63yo M with T4N2cM0 SCC of the right tonsil" rather than "63yo M with tonsillar cancer." Getting to pre-op early and doing good exams - doing things like Phalen's test for forearm flaps, etc, and this was unprompted. On rounds s/he took note of all drains, dressings, etc that needed to be pulled, changed, etc and then did those tasks, but only after checking with the intern (always check! we've had students go and pull drains very prematurely without asking - obviously that's our fault in the end!). This stuff isn't rocket science - however, the ability to perceive these things and do these tasks in a mature, efficient and visible yet not-too-visible way varies greatly between students. Know your capabilities and also know your boundaries. And, if you don't, ask! The bad rotators never wrote pre-op notes and when they were asked to, they cut and pasted. They were the last to show up, the first to leave. They didn't read before cases. They didn't take advantage of downtime (the little there is) to ask residents questions about scans, patients, etc (in a non-annoying way, of course!), they did crappy presentations, etc.

Surgical skill, at least at our program, is not something we are evaluating the students on. I can remember one student who did a really fantastic job suturing up lacs and s/he subsequently was allowed to do more and more. This is the only student i can remember residents and attendings talking about skill-wise at rank meeting. It by no means reflected poorly on others, but it was a nice bonus for this person. I can remember some students who I thought had horrible hands, but we didn't mention that in their reviews - not the point at this stage in your training.

Finally, I think as a fourth year you should get the chance to do some suturing. Again, probably not a subcuticular closure after a thyroidectomy on a 30 year old woman. That is obviously very resident and attending-specific. If you work with the interns and 2's all the time, you're probably not going to get much of a chance because they are working on their own skills and need all the practice they can get. Ask if you can put in drain stitches - maybe it's just me but I feel like those were very daunting at first; ask if you can put in the trach flange sutures, etc. I'd also recommend going with the resident to see facial traumas and asking if you can help sew up some of the less complicated lacs. If there are other things you'd like to try in the OR, doesn't hurt to ask the resident first. Maybe he/she will ask the attending if you can do some things. I usually ask the attending if it's ok if the student can to a whirl navigating through the nose with the scope and image guidance and maybe medialize the middle turb or something fairly harmless.

Finally, do a good job on your presentation. Pick an interesting topic; make sure your citations are up-to-date; aim to teach everyone something new; and DON'T GO OVER THE TIME LIMIT! (most frequent offense and pisses people off!).

Best of luck.

 

[JP2740]

Any 3rd year advice including books to read and study? I'm starting an ENT rotation tomorrow

 

[VisionaryTics]

Any 3rd year advice including books to read and study? I'm starting an ENT rotation tomorrow

If you're interested in ENT, ENT Secrets is older (2004 or such) but excellent. Know which cases are going every day, and read up on the anatomy in whatever text you have. If you have time, the journal "Operative Techniques in Otolaryngology" has nice short articles that cover the approach and management of specific surgical problems.

ENT is difficult because we get almost zero exposure to it M1/M2 and the core clerkships, so you really have to read voraciously when you're starting out.

 

[Leforte]

- doing things like Phalen's test for forearm flaps, etc,

For the rotators, Allen's test is a clinical test of the radial and ulnar arterial supply to the hand pre op

The Phalen's test is a test for nerve entrapment post op - we didn't do this regularly as we tried to limit movement of the arm/wrist/hand and just used touch for sensation and subjective feelings of numbness

 

[koojo]

Any 3rd year advice including books to read and study? I'm starting an ENT rotation tomorrow

I second ENT Secrets. Much more readable than the ENT book by Pasha. I also used emedicine for much of the anatomy and procedure details.

 

[neutropeniaboy]

ENT Secrets is the book I recommend for rotators. It's filled with practical advice and nuggets of information. If read from cover to cover twice over, you will shine from a fund of knowledge standpoint.

 

[surgicel]

what are the expectations of a good student that you would be like " this guy did well I could vouch for time during interview season." The problem is that every place is so different I was on a rotation earlier this year where I was not informed of my expectations at the start besides, rounding on 2-3 patients, scrubbing in the OR, and seeing patients in the clinic, towards the end one of the residents tells me I didn't perform at the level of an intern and tells me I should have done more. I respond by saying no one told me to do other things and they replied by saying "we're not suppose to tell you, your just suppose to know what to do". Does that seem reasonable?
Can someone list the tasks a great Sub-I is suppose to perform besides
pre-rounding/ rounding/ daily notes
Scrubbing in OR cases,
Seeing clinic patients

What duties of an Intern should you be taking on as a Sub-I?

 

[OtoHNS]

Can someone list the tasks a great Sub-I is suppose to perform besides
pre-rounding/ rounding/ daily notes
Scrubbing in OR cases,
Seeing clinic patients

Well, this list sounds like the bare minimum that any medical student should do on any surgical rotation.

Read the first post in this thread again. If you're still unsure of what you did wrong, consider asking to sit down with an attending from that rotation and get a candid evaluation on what you should have done better.

 

[neutropeniaboy]

I respond by saying no one told me to do other things and they replied by saying "we're not suppose to tell you, your just suppose to know what to do". Does that seem reasonable?

No, it doesn't.

If what you are saying is true, it would seem to me that your residents are being unreasonable and arrogant. They certainly aren't selling their program very well.

Could you have said or done something to upset one or more residents?

Could you have not done very basic things?

 

[surgicel]

I have read the original post and there is no mention in it of Sub-I's having to write pre-op notes which someone mentioned above should do. I agree that I may have under perform for the rotation, which is why I'm asking besides what I was doing what other duties should I have taken on: put in patient orders? help write pre-op and post-op notes? I have other Sub-I's and want to get the next ones right.

It was odd b/c feedback and expectations were different from the team: one of the senior residents said I did a decent job, but my intern mentioned that I didn't perform at the level of a Sub-I and didn't take control of my patients ( what does that mean besides following-up on patients and rounding on them twice a daily.) I sat down one of the attendings and asked what they wanted out of me and they simply said, " see our interns that's what we want you to be like", so that wasn't much help.

I know every place has different expectations, is there a list of tasks a sub-I should generally be able to perform, once again the op is not much help in detailing those tasks, besides mentioning helping out the team of residents as much as possible

 

[Tatastrophy]

I have read the original post and there is no mention in it of Sub-I's having to write pre-op notes which someone mentioned above should do. I agree that I may have under perform for the rotation, which is why I'm asking besides what I was doing what other duties should I have taken on: put in patient orders? help write pre-op and post-op notes? I have other Sub-I's and want to get the next ones right.

It was odd b/c feedback and expectations were different from the team: one of the senior residents said I did a decent job, but my intern mentioned that I didn't perform at the level of a Sub-I and didn't take control of my patients ( what does that mean besides following-up on patients and rounding on them twice a daily.) I sat down one of the attendings and asked what they wanted out of me and they simply said, " see our interns that's what we want you to be like", so that wasn't much help.

I know every place has different expectations, is there a list of tasks a sub-I should generally be able to perform, once again the op is not much help in detailing those tasks, besides mentioning helping out the team of residents as much as possible

I always the residents ask up front about what is expected of me on the rotation. At my home institution, on core rotations and even some electives, you are expected to basically do/be able to do everything that it takes to care for your patient....and have a resident/attending sign things like orders and such. On one of my aways, they've essentially removed all clerical daily responsibilities from their Sub-Is and on one of the services, they even discouraged us from pre-rounding. I still did, because I do not like to walk into bad surprises on rounds and want to make sure my patients are doing ok but at one point I had to ask to clarify: "I am doing my best to be a good member of the team, is there anything I could do to make your guys' jobs easier?" Nope, I was doing exactly what they wanted me to do-they just encouraged me to have fun and learn a lot. Point is(and forgive me if I misunderstood the timing of all this), end of the rotation should not be the first time someone broaches the subject of expectations.

Besides that, maybe some of these rhetorical questions may help:
Were you on this rotation by yourself or were there other students rotating with you? What did they do?
Perhaps the residents wanted you to take call with them?
If a consult came in, did you volunteer to go check it out with the intern?
On H&N, were you always/nearly always ready help re-dress the wound sites?
If on a service that allows this, did you volunteer to go see clinic patients on your own?
When you'd see a patient on your own (like clinic) did you go through DDx/Assessment/Plan or did you just state the interview/exam findings?

 

[Leforte]

I agree that you should ask the residents what is expected up front. Usually at the start of a rotation (away or local) there are a few medical students and everyone is thinking of this question.

You could also ask, what have people done in the past to excel. There are oftentimes small things that really stand out. If there are critical patients that the team is watching in the unit or on the floor, stepping in to the OR and giving a status update is always nice. As is notifying the team of any key consults the are pending. If a trach consult comes in - go to the patient, figure out why the teach is needed, write a good note, get the patients NPO status, in they are anti coagulated, what the vent settings are and what their neck anatomy looks like (thin, obese, previous H&N surgery, etc). These things, although seemingly minor, really help the team out by having the rotators serve as the eyes and ears of the team. It saves heaps of time at the end of the day, especially if you can get an add-on case on the board in a room that finished early.

When I have students who do these simple things - they get to do the trach with the resident while I watch.

If a peds consult comes in for stridor - go see the patient, get the background, write a preliminary note, fetch the flexible scope and let the team know.

If an epistaxis consult comes in, see what is going on - what are the vitals, INR, BP, what preceded the epistaxis (cardiac cath, trauma, elevated INR, etc) - get what the team uses for these things - i.e. headlight, nasal packing tray, merocels, nasopore, oxymetazoline, etc.

It is the simple things, really, that when done in conjunction with what is expected that make someone stand out.