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 havent 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. Im not here to validate the reasons underlying the desire or need to do these rotations, but lets 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 doesnt take long to look at the list of achievements to know that the average otolaryngology resident isnt 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 doesnt mean you cant be quiet and reserved; being a normal person doesnt 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 isnt 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 cant translate knowledge into clinical practice. Being smart doesnt make you a good clinician; it helps, but it doesnt make. Respect: Is it not expected that one should look another in the eye or shake hands? Is it typical to introduce ones self when entering a room when that individual is new or unexpected? Every great student that Ive encountered has walked up to me, reached out his hand (when Im not scrubbed, of course) and has introduced himself or herself. Theyve 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 Im 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, its 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. Im 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. Ive 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. Ive been personal witness to (and have heard via complaints) students disrespecting nurses. Ive seen this in the clinic and Ive 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, youll 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. Its amazing to me that students permit themselves to bark orders and demands about when and where things get done. Sexual discrimination/Racial discrimination. Im 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. Ive seen students openly make disparaging comments about patients right in front of me: from a student saying, thats 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? Its not. If youre 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 doesnt want that or need that, its 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, dont forget what you are doing: sub-internship (sub means beneath), acting internship, audition rotation. Dont forget your place, and thats 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; Ill 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 its 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 isnt specifically prohibited, ask to take call. Do not demand it, because maybe the residents dont want you to. I cant imagine a resident who wouldnt love to have you write a note in the middle of the night or help with working up a patient as long as you dont 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 dont know what Im doing in the OR, Id 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 whats 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? Isnt 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 havent practiced tying knots on your lab coat, the back of someones 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. Im also interested in how you get coached by me and the resident and how you improve while on your rotation. Ill 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: Dont ever schedule Step II or any other exam during an ENT rotation. Dont ever pout because a resident says you cant close or because a resident has asked you to stop so he or she can take over. If they dont want you to close, its because the resident needs experience, the resident knows the attending wants it that way, the resident feels rushed, or the resident simply doesnt 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 its hard when you want to do so much, but your time will come; now isnt 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 theyre 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.