how to be useful, socially tactful and shine?

[threecoins]

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I am an International medical student who will be spending 2 months in Emergency Medicine and surgery electives in a US university hospital, my step one score AIN'T great ( 207 when the mean was 215) but I am sure I can get better on step two. I am doing these electives to improve my chances in getting a surgery residency . I have a few questions , any feedback would be greatly appreciated:
1- I wonder what are the skills I should know to shine In the EM and Surg electives? I mean compared to MS-4 American students who will be doing the electives with me. here is what I CAN do and what I CAN'T do please tell me how is that and what things do i need to work on
I can do a good H&P ( I am kinda familiar with american style in performing but not in writing it out) , I have done only 2 or 3 per rectal exams, I can insert a peripheral venous cannula ( I still miss the vein many times) , I have done two or three needle thoracocentesis procedures( without complications).I can give Intramuscular and intavenous injections. Now to the I CAN NOT do that (YET) part ,well I can't put on a central venous line, only theoritical knowledge on CPR and ACLS( I know that is a shame but we dont do that here), I have seen sutures done a few times but never ventured myself coz most of the time it is done without anethesia in my school ( I read about EMLA and stuff in the US, but we do it PLAIN here)
so the question is compared to other MS-4s will I sound like a total useless being hovering around ..... or useful or what? what are the special skills I need to learn to be impressive( plz dont say opthalmoscopy)
2- like I said earlier,I am doing these electives to improve my chances in getting into Gen Surg residency,the question is SHOULD I BE CLEAR about this from the BEGGINING or shall I just try to work hard without making the attendings and residents NOTICE that I am trying to catch their attention to get a good letter of recommendation, I am spending too much money on those two months and my trip would be a total failure if I go home without securing one or two strong LORs...so shall I show all my cards up on the first week I go there like hey people, my name is ....I am from .....final year , my step 1 aint that great and I am here to strengthen my profile....etc or shall i just appear I am there for fun( although I am not ) and just for the experince of it....like many other international students who are there without the intent to pursue a US residency forward. I am a little confused by the complex hospital politics between students, residents, attendings etc i read about in the clinical rotations SDN forums..I dont want to appear as an A****hole or someone who is availing himself of every opprtunity for fellow students, although these 2 months are MY ONLY chance in the US to secure those LORs...please advice me on hwo can I strike a balance and be a tactful player....
3- I will also get clinical evaluations for my two electives, do you think that these also count ( beside LORS) when I apply for residency ( I am not sure how i ll present them to the residency commitees since the ECFMG only requires transcripts from my original school but perhaps i can hint to them in CV or sthing)
I would be VERY grateful for all sincere feedback.

 

[Winged Scapula]

I'll address a couple of your concerns.

If you wish to compare favorably to US medical students, you will be expected to have some knowledge of how to suture - at least interrupted skin sutures for EM and the additional of mattress sutures, ties, surgical stapling and subcuticular sutures for a Surgery rotation. No one expects you to be great at these, but IMHO most 3rd year US medical students are capable of doing these, at least with some assistance. Most are done with local anesthetic here.

While US medical students do put in IVs for the practice, for the most part, IVs and injections (both IM and Sub-Q) are done by nursing staff. I doubt you'll be asked to do either as a 4th year rotating here but you are always welcome if you wish to do so (especially IV starts). Many US medical students do not know how to do central lines; some will get experience during medical school, some will get good and others will never have the opportunity to do so. I wouldn't worry about it.

You will need to learn how to write up an H&P in the US style as well as read one. Doing the exam is great but if you can't communicate your findings on paper to others, its almost as if you didn't do it. There are lots of books which can help you with this.

best of luck...

 

[grouptherapy]

my two cents. what you need to bring to your upcoming rotations is the correct attitude. if you have this, everything will fall into place. a) be aggressive b) don't be an ass. there's a fine line between the two. always ask to do every single procedure and be the first one out of the group to do so; the worse thing they can ever say is no. never show up your attending, resident, classmate, nurse or tech. never publicly correct these people. never yell out an answer to a question posed to your classmate;let them answer. if he or she is stuck and the attending/resident turns to you for an answer, then it is alright to do so. it is alright to bring krispy kreme donuts and coffee for your team in the mornings; they will appreciate the gesture. BE THE FIRST ONE IN AND THE LAST ONE OUT. come in on weekends and days off to work. look or fake energetic. never complain about anything. smile.

EM: present your pt. in a concise manner, in H&P order, by rote. always pick up a chart on your own accord (if allowed). never wait until they have to give you one. all you need to know is the instrument tie. the p.a. or resident can teach you how to staple, dermabond, cast. keep track of your patients (write a list of what labs are pending and check periodically/religiously without being asked). ask to put in central line, intubate.

SURG: know your patients and have their lab values handy (preop and postop). scrub in as much as possible. learn to love to suture. they'll expect you to know how to two hand tie well by the end. one hand tie is very useful. be aggressive and ask to do mattress and subcuticular, central lines, chest tubes. if you don't know how to do something, ask. volunteer for foleys, phlebotomy, IVs. work the hardest. be the best.

good luck

 

[md03]

What students are allowed to do procedure-wise varies greatly by program.

Where I went to med school, the 3rd year students did most of the ED type suturing (no EM residents, surgery residents too busy, so the students on the surgery clerkship do 80%). Also the 4th year students generally got lines, chest tubes, etc glaore. No injections and rarely did we start peripheral IV's...the nurses did that. (though we could if we wanted to)

Where I am currently doing my residency, I am actually doing far fewer procedures as a resident than I did as a student. There are fewer lines and more PICC lines (which are placed by specially trained nurses). A 4th year student would be lucky to get one line during a rotation. Very little suturing in the ED, as the EM resdients do it all. However, the students are allowed to do some subcuticular closures in the OR.

You should learn how to do simple interrupted sutures, even if you never do it on pts (pig's feet are great for this purpose, if you do your rotations where people consider them food, look in the grocery store meat section for them)

Your best bet is to know your pts well, work on your H&P writing (and SOAP note writing) skills. Ask to do any procdure, help the 3rd year students with their notes, plans, etc. Dont mention your step 1 score (except the folks you get to write your letter should have that along with your transcript and personal statement). Make your interest known.

 

[threecoins]

Thanks Kimberly ?well in my country students are allowed only to do interrupted sutures, Subcuticular are done mainly by surgery and plastic surgery residents, skin stapling ain't done at all. Since I will be doing the EM first can I just try to grasp these while I am in the US instead of learning them here coz I guess there must be some subtle differences in the technique and once you learn something in some style it is hard for you to change it..how long do you think it will take me to grasp these sutures? Any hope of being decently trained in them before my EM elective finishes?

 

[threecoins]

Thanks grouptherapy for the tips : you have just said I should be the first one of the group to ask to do a procedure ?well I don?t think I can be the first one to ask simply coz I don?t know what procedures are medstudents expected to do , may you can kindly help me by giving me a list. I mean can a medical student do ANY procedure, I don?t wanna ask to do sthing and find everybody looking at me as if I am from MARS for venturing to ask to do sthing I am NOT expected to do. I understand it differs from one school to another but I wann know how far can I go.
By the way there is something that confuses me , do you think the EM is a good place to learn, I mean I CAN not imagine how will they let me intubate or do a central line on a patient coming in an Emergency situation when every minute count and there is probably no place for the shaky May-I-intubate foreign student?? How can I go through the lines to get to do sthing without appearing intruding or endangering pt's life?
You have advised me to scrub in the SURG as much as possible, what can you do when u scrub in, just watch? Hold retractors? And if so why scrub in so much? ?excuse my naivity

 

[threecoins]

Thanks md03: highlighting the variable nature of schools procedure-wise was great, PLUS you were the only one to advise me on mentioning my step 1 score?and for " making my interest known", the question is to whom shall I make it known and to whom I should not, shall I make it known to other US students rotating? To other IMGs rotating? To residents? All attending I get to meet or only the ONE who will write me the letters? By the way my elective description says that I will be assigned an instructor of choice to study a specific part of surgery in depth: who do you think that " instructor of choice" will be: a resident, chief resident or attending? If he is an attending what special treats should I offer my instructor? Should I explicitly him if they can write me a letter on the first day or later

 

[threecoins]

I would really appreciate it if anyone who reads this thread would share his opinions on the questions asked, thanks

 

[neutropeniaboy]

Originally posted by threecoins
I mean can a medical student do ANY procedure, I don?t wanna ask to do sthing and find everybody looking at me as if I am from MARS for venturing to ask to do sthing I am NOT expected to do.

No. That's not the case. It is rare that a 3rd year medical student does any significant procedure. I've only occasionally seen a 3rd year medical student put in a chest tube. A little more common, but not THAT common, is a 3rd year student putting in a central line. You should be able to put in IVs, EJ IVs, cast, reduce, I&D simple abscesses in the ER. As a 4th year, you'll be expected to do more of these things.

I never put a single chest tube in as a student. I didn't even put one in as an intern. Oddly, I did my first the other day when I was in the trauma room, when I was working up the patient for a temporal bone fracture!

I never put central lines in as a student; I did my first as an intern and ended up getting sick of doing them and finding excuses not to do them by the end of the year. Your experience will come.

I did cut downs as an intern, never as a student. I drained abscesses in the OR as a student (but, I never did an EM rotation as a student).

Come to think of it, I didn't do many procedures as a student, and I'm pretty competent now as a surgical resident. I don't think your medical school experience will have much bearing on how you turn out as a resident. Of course, if you do a lot during your medical school years, that will help. But, I don't think having done few will burt you.




By the way there is something that confuses me , do you think the EM is a good place to learn, I mean I CAN not imagine how will they let me intubate or do a central line on a patient coming in an Emergency situation when every minute count and there is probably no place for the shaky

You've been watching too much e.r. Most emergency rooms, while busy, busy, busy, aren't involved in any sort of emergent care. I got to intubate some as a 3rd year (certainly not emergently), and as I said, I didn't do any central lines. You'll find out that a lot of the people in the ER who get central lines don't actually get them emergently. They end up being gomers or IVDA who are going to get admitted and the nurses have failed to get a PIV.

You have advised me to scrub in the SURG as much as possible, what can you do when u scrub in, just watch? Hold retractors? And if so why scrub in so much? ?excuse my naivity

Probably not much, depending on the surgery. If you're doing bowel surgery, don't expect to do much. The same goes for most advanced cases. However, you might be permitted to close the skin if you've proven to be enthusiastic or a good retractor. On the other hand, if there are some little cases like I&Ds or excisions of cysts, warts, hemorrhoids, etc., you may be permitted to do them under the supervision of the attending.

As an example, as a 4th year on my ENT rotations, I was permitted to do tonsillectomies, neck abscess I&Ds, and some PE tube insertions. Not glamorous (and still not glamorous), but the attendings had enough confidence in me as a student to let me do it by myself.

You'll find that everything is variable.

All in all, I would say my procedure list as a student was pretty damn small, and I have to say that it's due to where I was educated.

 

[fourthyear]

I will reemphasize the show up early and leave late, never complain, always look interested and enthusiastic - all great traits in a future surgery resident.

Frequently ask your residents what you can help with. Don't be afraid to ask quetions or volunteer to do things - you're there to learn. And the more you ask, the more interested people know you are. YES, let everyone you see know you want to go into surgery. I wouldn't bother to mention your step1 score, it will be on your application, no need to bring it up in conversation unless anyone asks you (i'd say this advice whether your score was 180 or 260). You just need to let them know you love surgery and want to learn as much as you can b/c you want to be a surgery resident next year.

Read up on all the patients - this seems to be the best way to impress attendings in surgery. Find out the OR schedule the day before and read up about what you will be in on the next day. You should know anatomy of that procedure very well - when med students don't know basic anatomy, it looks bad. Also know the patient's history and why they are doing this operation for this patient, as well as the common complications of the operation. These are the things attendings will ask you, and it only takes a little extra reading time every night to impress them.

No one expects your procedural skills to be much at this point - even as an intern they don't expect us to know how to do things without lots of guidance yet. But they DO expect us to know our patients well, work our tails off getting things done around the hospital, and read about cases before we do them.

 

[fourthyear]

oh, as to the "why scrub in if i'm not doing anything" question - wrong attitude!!! If you love surgery, you love the OR, whether you are doing anything or just watching - especially as a student you will mostly just watch and hold retractors. You need to spend as much time in the OR as possible to make sure you like being there. Plus, it is your time to get to know attendings, who will be your letter writers. That's where they are all day, so you need to spend as much time as you can there.

I don't know how this place will set you up- whether you'll report to an attending or resident or fellow or what. But whovever it is - stick with them or someone from the team at all times. Never just dissappear to get lunch or study without being told to. Always make sure you've checked with everyone on the team to be sure there's nothing else you could or should be doing at the time.

 

[threecoins]

very heplful comments neutropeniaboy ...actually yes I have been watching too much ER🙂 but not lately, I checked the admission figures for the emergency room where I am going, they get 30,000 pts each year of which only 1000 trauma cases, so I guess you are right coz most cases wont be THAT emergent, I guess this means more learning opprtunities for me.
..fourthyear, thanks for the input especially being CLEAR on letting EVERONE know I am willing to go into surgery..and for advising me to read up on the pts and operations...by the way what books do you folks use for surgical anatomy? in my school we take an " operative talk" exam in the finals , we are supposed to know details of Hernia repairs, thyroidectomy, appendicectomy, Cholecystectomy and mastectomy, I wonder if these are the same major things done in GS in US hospitals or there are otehr thinsg u need to know( hemicolectomy, transplant etc)?
because the system of clinical teaching is very different in my country where most of the actual clinical experince is postponed for the pre-graduation obligatory internship year, even then we aint allowed to do much , I would really appreciate it if someone gives me a 1,2,3.. exhaustive list of the basic duties of a fourth year US student , things they must do on both SURG and EM electives( or rotations) and things they should NOT do...I mean can they admit patients alone, what decisions can they make about treatment , diagnosis , can they order labs, X-rays..?although I am getting an idea from the posts but i need something more clear, I still can not get where is the well defined.' student-territory' of duties in a US teaching hospital, all commenst are welcomed.

 

[willow212]

I'm not applying in surgery, but from having been through the 3rd year experience, my opinion is that each team of interns/residents/attendings is highly variable in what they expect you to do or not do, so the best thing to do is to ask right off the bat (to each person on your team):

1. what is expected of students
2. that you are going into sgy and what can they recommend that you try to do during the rotation to learn what they feel is impt in surgeons
3. any things they don't recommend students do
4. before volunteering for things you're not sure about, ask your resident/intern if it would be okay for you to volunteer.
5. ask other med students at that location what students are normally allowed to do

Since each person has a different style, I think they would appreciate if you clarify things at the beginning. And this shows you are interested in their opinion and in doing well in the field as well.

Best of luck.