This is a long post so bear with me. Thinking about this helps me evaluate myself as I go through the end of my 3rd year as well. Assuming you mean the evaluation portion of the grade rather than the shelf exam portion... Your clinical grade is going to mostly depend on three things - knowledge, work ethic, likability (not in any particular order). Theres some other things that go into this equation, but these are big ones in my opinion.
1) Knowledge: You don't have to be the smartest person in your class to be evaluated well in this category and you don't have to know
everything - the key is to know the answers to questions at the right time (i.e. whenever a resident or attending is asking them). Read about the patients you're following so that on rounds the next day you can answer questions about general concepts of conditions they have. I personally liked to either read this information in my review books that I was using to study for the shelf (which may be a little slim on the info somtimes though) because you're killing two birds with one stone. If your school/hospital has access to uptodate.com then that is an excellent resource in my opinion too. Make sure you know what kinds of tests have been ordered for your patients (esp what has come back within the last 24 hours) and be ready to interpret all of this data on rounds or any other time someone might ask you. i.e. If a patient had cultures drawn have an idea of when that type of culture comes back and be there to report it ASAP. You should also have a general idea of oother patients on the service (even ones you're not following) because you may have the "opportunity" to answer questions about these patients as well. If you're on a surgery rotation then read about the surgery before you go scrub so you can answer questions in the OR yadda yadda yadda. The bottom line is to know the right information at the right time ALWAYS and you will be evaluated as having honors-level knowledge.
2) Work ethic - Show up on time (NEVER be late). Always give yourself enough time to pre-round and write notes if that is what you do on that particular service. Keep your residents updated on any new labs or findings that you think they might not be privy to (even if they actually already knew it) because if you save their @ss on rounds when they know something because you told them about it they are going to love you. Look a what the interns are doing and try to emulate it. If they grab the charts and scribble down orders that the senior resident is spouting off during rounds then (if its within your bounds) you should start doing that. Its one less thing they have to do and, hey, you get to learn how to write orders. The interns and seniors will take note of this and be happy about it. If they always write post-op notes on patients, you could probably start doing it to (obv just gotta make sure someone co-signs anyhting you do). If you know a patient in the ER is going to be admitted to your service then take the 5 minutes to write the admit orders. If it turns out you're wrong and they're not getting admitted or you wrote some wrong orders then no sweat - at least you got to practice and maybe had someone look it over for you to tell you where you screwed up. Any opportunity you have to go above and beyond the call of duty is an opportunity to show people that you have a great work ethic. I'm not saying you should volunteer to do all the scutwork, but the residents are busy and if you help them out with some stuff it may give them some extra time to interact with you when they don't have a million other things to do. Just don't step on anyones toes or harm any patients in the process. If you get a LOR out of a clerkship where they say "We would definitely recruit this student to our program" based on your work ethic then you are fricken' golden. Make every rotation a rotation where someone would OFFER to write a letter that says that.
3) Likability - I'll try to expand on this a bit because over the course of 3rd year so far I've seem some social ******s. Some of these are exceptions to the rules stated above.
Never throw your classmates under the bus. As I stated earlier you should have a general idea about all patients on your service (even ones you arent following) so you can answer questions about them if the opportunity comes up. If a question is asked about a patient on the service that your fellow medical student is following and they don't know the answer you could make them look bad depending on how you answer. Use discretion here because you may look like the lifeiline that is saving your classmate or you may look like the deuchbag that is trying to impresss people at the expense of others (the latter group is sadly mistaken usually). On the opposite end of the spectrum if your classmate points out a heart murmur to you before rounds because they weren't sure about whether it was systolic or diastolic or something you can mention on rounds when that patient is being discussed "Yeah so-and-so picked up on that this morning and gave me the opportunity to listen to it." Pumping up your team member in this way makes them look good and really makes you look like a team player. Try not to make it look to obvious though, just slip it into the conversation if the opportunity allows.
Don't disagree with or question your superiors. If something they are doing is about to endanger a patient's life it is a different story but in general they probably know a lot more than you and have a lot more experience. You must realize that sometimes (actually many times) the textbook answer is not the only answer when everything else is taken into consideration. Use this as an opportunity to ask questions and learn something new. As long as you're not being annoying the residents may actually like the idea that you're asking intellectual questions about why they may be doing something different than you learned it out of a 1999 edition of First Aid for Pediatrics.
Don't try to spout off a bunch of medical nonsense every time you have the podium just to show everyone how much you know. Even if you could recite Harrison's word-for-word you could get a bad clinical evaluation simply because you're always perceived as showing off and stepping on the feet of others. Know your place and answer questions when you're asked them. Attendings and residents have been around the block and they know who is a total toolbox. Don't be that guy/girl
Without being annoying make sure people know your name. If you're on a surgery clerkship and your scrubbing with 5 different surgeons throughout the course of a month they may not remember who the hell you are when its time to evaluate you because they certainly aren't paying much attention to you in the OR. When its appropriate, introduce yourself and make conversation to get some face-time. The key here is "when its appropriate." You'll have to use your discretion again, just don't be annoying about it.
Engage in casual discourse with your residents as appropriate. I found this particularly easy on surgery because I am a guy and I want to do surgery (sorry if that sounds sexist). You're not assigned to a service so that you can make new friends, but if the opportunity allows for you to get dinner with the residents on yoru team and talk about stuff outside of your clinical duties then by all means do it. We're all human. However if this isn't going to happen because your personalities just don't mesh, then don't force it. People may have positive memories about you that have nothing to do with medicine. That is a good thing when its time for them to evaluate you but it is not necessary. For example I didn't really have much in common with people on my pediatrics rotation, but I still got honors without really doing anything besides showing up on time and working hard.
Don't be a grade-grubber. You can do everything I've said in this post without making it obvious that at least some part of it is in order to get honors. DON'T ASK ATTENDINGS AND RESIDENTS WHAT YOU CAN DO TO GET HONORS. You can ask people in classes above you what they think might get you honors and you can ask your attendings and residents what you can do "to be a better member of the team" or "to get the most out of the rotation" or somethign like that without sounding like you're only out to get the big H. Nobody likes to hear about this including your fellow classmates that you're rotating with.
There is a lot mroe to this category, but the bottom line is that the more people like you the more likely they will be to evaluate you highly on ANY PART OF YOUR EVALUATION whether you deserve it or not. This is psychology people.
Going overboard in any of the above categories may end up making you look like a suckup or something along those lines. You can be the best student ever on the rotation however and still make it not look like you're sucking up at all, you just have to re-evaluate what you're doing to make sure that its not going to be perceived in the wrong way. So all in all if you maximize the above 3 components I will gurantee that you get clinical honors. Now you just gotta ace the shelf
