How to honor a clerkship

[Waldeinsamkeit]

Any advice on best way to honor a clerkship? My school weighs the grade from the Physician more heavily than the shelf exam, so it is not like I can test into it. I try to show up early, be interested, anticipate tasks, and ask an appropriate number of questions. I am not sure what else to do. I have not gotten my grade back from my first block, so I am not certain if my strategy is working or not.

Thanks for any and all input.

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[Redpancreas]

You should ask a more specific question because an entire essay can be written about this. There's an entire forum where people have done this. Do some browsing or consider rephrasing your question: Clinical Rotations

 

[sliceofbread136]

Do you get to present your own h+ps? The best way in my experience is present a broad and pertinent differential (this can be hard at the start, try up to dating the chief complaint or get an EM textbook). Follow that up with the management of what you think the problem is and support that management choice with data on why it is effective (UpToDate also helps for this). They also love score for whatever reason, so things like Wells criteria are great.

That being said it’s mostly just luck

 

[NYCdude]

Don't bother, it's impossible.

 

[DBV]

Fully convinced its all luck and chance. I somehow honored surgery when I routinely skipped surgical cases to go home and nap. Just happened to have nice residents.

 

[Lawpy]

That being said it’s mostly just luck

Don't bother, it's impossible.

Fully convinced its all luck and chance. I somehow honored surgery when I routinely skipped surgical cases to go home and nap. Just happened to have nice residents.

If honoring clerkships is entirely based on luck, how are some students able to honor all rotations in third year? And why are program directors at competitive places obsessing over honors?

 

[sliceofbread136]

If honoring clerkships is entirely based on luck, how are some students able to honor all rotations in third year? And why are program directors at competitive places obsessing over honors?

Personality plays a huge role. That and luck are the two largest factors. There are clinically pertinent things you can do to positively impact your grades (like I mentioned in my post), however these are way overshadowed. You also aren’t factoring in shelf scores.

Pds obessess over honors because of the overall lack of metrics. Doesn’t make it a good metric.

 

[Matthew9Thirtyfive]

If honoring clerkships is entirely based on luck, how are some students able to honor all rotations in third year? And why are program directors at competitive places obsessing over honors?

How many students honor every rotation, and how many don’t honor a single one? If it were mostly chance, you wouldn’t expect either of those populations to be very large.

 

[Redpancreas]

Personality plays a huge role. That and luck are the two largest factors. There are clinically pertinent things you can do to positively impact your grades (like I mentioned in my post), however these are way overshadowed. You also aren’t factoring in shelf scores.

Pds obessess over honors because of the overall lack of metrics. Doesn’t make it a good metric.

A student's cunning (finding loopholes in grading, getting on a resident's good side, choosing the right one's to evaluate them) isn't accounted for. If we could somehow quantify that factor and do a study, I'd guess it would be most linked to clinical honors. PDs value the clinical grades because a portion's objective and even subjective evaluations will become more reliable with a large sample size with a potential for patterns. As for why some PDs screen for honors in their specialty, like I've said before, there's no shortage of candidates with it so nothing's stopping them.

 

[Mad Jack]

Depends on how your school grades. At mine, your personality pretty much 80% determines your honors status.

 

[wiloghby]

Depends on how your school grades.

QFT!! It is entirely school dependent.

At my school, the shelf exam -- aka 3 hours on the last day of the clerkship -- is all that really matters.

 

[libertyyne]

How many students honor every rotation, and how many don’t honor a single one? If it were mostly chance, you wouldn’t expect either of those populations to be very large.

approximately 5% of students honor every core rotation at my school.

 

[wiloghby]

How many students honor every rotation, and how many don’t honor a single one? If it were mostly chance, you wouldn’t expect either of those populations to be very large.

Sort of.. if it's random and just some fixed probability for each clerkship it would be a binomial distribution. If every student is studying and trying their hardest resulting in some number of honors' over the course of their third year, that would probably be normally distributed.

These two distributions can look awfully similar when you bust out a histogram.

But, back in the real world, I don't think the majority of schools are truly randomly assigning honors to people. Yes, you may get unlucky or lucky one or two times over the course of the year, but the big picture should tease things out.

 

[valid username]

I honored mine, and I ranked very high for my clinical years in spite of ranking pretty low for basic sciences. My MSPE comments are glowing--to the point of embarrassing. Obviously, you have to be on time, motivated, positive, imterested. If you see an opportunity to make yourself useful, then make yourself useful. For the love of your chosen diety--do not stop to think about whether it's your job or not. I cannot count how many times I have heard students say "that's not my job." You're a student. You have no job.

I never went out of my way to impress an attending. I am not going to stroke anyone's ego unless they need it. None of my attendings needed it. On the other hand, I always went out of my way for patients.

If someone cried, I got them a tissue.
If someone was crying and holding their phone, I offered to find the name for them.
If a patient vomitted, I helped clean them up--and I stroked that ego 😉.
If a patient was cold, I got a warm blanket.
I had a pt that needed to fly home at discharge, but had no ID. I called TSA and found a way.
When our freshly delivered mom had a not numb perineum, I made sure the Dr. noticed.
Except the time we had a 2nd baby with decels, I coached that mom thru sutures like a pro.

You can argue that these things don't make you a better doctor. That may or may not be true. But the thing is, if you can focus on making things better for each pt you encounter you will learn.
And you will get glowing commemts. I got A's from attendings who supposedly don't give A's.

 

[Redpancreas]

I honored mine, and I ranked very high for my clinical years in spite of ranking pretty low for basic sciences. My MSPE comments are glowing--to the point of embarrassing. Obviously, you have to be on time, motivated, positive, imterested. If you see an opportunity to make yourself useful, then make yourself useful. For the love of your chosen diety--do not stop to think about whether it's your job or not. I cannot count how many times I have heard [other] students say "that's not my job." You're a student. You have no job.

I never went out of my way to impress an attending. I am not going to stroke anyone's ego unless they need it. None of my attendings needed it. On the other hand, I always went out of my way for patients.

If someone cried, I got them a tissue.
If someone was crying and holding their phone, I offered to find the name for them.
If a patient vomitted, I helped clean them up--and I stroked that ego 😉.
If a patient was cold, I got a warm blanket.
I had a pt that needed to fly home at discharge, but had no ID. I called TSA and found a way.
When our freshly delivered mom had a not numb perineum, I made sure the Dr. noticed.
Except the time we had a 2nd baby with decels, I coached that mom thru sutures like a pro.

You can argue that these things don't make you a better doctor. That may or may not be true. But the thing is, if you can focus on making things better for each pt you encounter you will learn.
And you will get glowing commemts. I got A's from attendings who supposedly don't give A's.

Congrats on honoring, but everyone knows you have to get on your evaluator's good side. This is just 1% advice, 99% humble-brag.

 

[valid username]

Congrats on honoring, but everyone knows you have to get on your evaluator's good side. This is just 1% advice, 99% humble-brag.

Not so much. I'm an IMG and very unlikely to match anyway 😉. I'm not saying you don't have to be on an attending's good side. I'm saying if you work hard you will end up on the good side.

And the reason I put the rank in there was to point out I am far from genious. I got highly satisfactory for the first 2 years (equivalant to--just barely passed), but got outstanding for the second two years. Again, it doesn't matter for me because I'm an IMG. (But I do rotate with AMGs.)

I'm sorry you don't see my post as advice. It was my intention. No one here knows me--there's no point in humble-bragging. My goal was to answer OP's question: how can you honor your clinicals? It was the ONLY thing i excelled at in all of medical school. I sucked at basic cienes, I got a 210 on step 1. Nothing worth bragging about there.

Believe whatever you want about me. I'm just a schmuck with a useless degree and a lot of debt, but I did honor my clinicals in the ways I described.

 

[libertyyne]

I honored mine, and I ranked very high for my clinical years in spite of ranking pretty low for basic sciences. My MSPE comments are glowing--to the point of embarrassing. Obviously, you have to be on time, motivated, positive, imterested. If you see an opportunity to make yourself useful, then make yourself useful. For the love of your chosen diety--do not stop to think about whether it's your job or not. I cannot count how many times I have heard students say "that's not my job." You're a student. You have no job.

I never went out of my way to impress an attending. I am not going to stroke anyone's ego unless they need it. None of my attendings needed it. On the other hand, I always went out of my way for patients.

If someone cried, I got them a tissue.
If someone was crying and holding their phone, I offered to find the name for them.
If a patient vomitted, I helped clean them up--and I stroked that ego 😉.
If a patient was cold, I got a warm blanket.
I had a pt that needed to fly home at discharge, but had no ID. I called TSA and found a way.
When our freshly delivered mom had a not numb perineum, I made sure the Dr. noticed.
Except the time we had a 2nd baby with decels, I coached that mom thru sutures like a pro.

You can argue that these things don't make you a better doctor. That may or may not be true. But the thing is, if you can focus on making things better for each pt you encounter you will learn.
And you will get glowing commemts. I got A's from attendings who supposedly don't give A's.

Could you do a larger write-up? I would love to hear more tips and tricks. Are there any other sources you used to model behavior on ?

 

[Matthew9Thirtyfive]

Sort of.. if it's random and just some fixed probability for each clerkship it would be a binomial distribution. If every student is studying and trying their hardest resulting in some number of honors' over the course of their third year, that would probably be normally distributed.

These two distributions can look awfully similar when you bust out a histogram.

But, back in the real world, I don't think the majority of schools are truly randomly assigning honors to people. Yes, you may get unlucky or lucky one or two times over the course of the year, but the big picture should tease things out.

The formula for PMF is P(x;p,n) = n!/(x!(n-x)!)*(p)^x*(1-p)^(n-x), where you look at x successes in n trials, where p is the probability of success and 1-p is the probability of failure. If success is an honors and any other grade is not, then we should decide what the probability is of getting an honors. If the grading system is H/HP/P/F, then by pure chance you can assume a 0.25 chance of getting an H in any rotation and a 0.75 chance of getting anything else (again, this is chance, and studying etc have nothing to do with it). Then the probability of honoring all your rotations third year (just picking 7 to include IM, psych, FM, surgery, OB, peds, and neuro) is 7!/(7!(7-7)!)*(0.25)^7*(1-0.25)^(7-7) = 1/16384 = 6.10e-5, while the probability of honoring none of those rotations is 7!/(0!(7-0)!)*(0.25)^0*(1-0.25)^(7-0) = 0.133. So, you have a much lower chance of honoring all your rotations, but your chances of not honoring a single one is not very good either.

So the population of students who honored all or none purely by chance will be pretty small, though the people who don't honor anything will be more numerous.

But yes, my point actually is that while I'm sure luck has something to do with it, there is definitely more going on. Having 5% of your class honor every rotation means it's more than luck.

 

[Matthew9Thirtyfive]

approximately 5% of students honor every core rotation at my school.

How many don't honor anything?

 

[libertyyne]

How many don't honor anything?

I dont know. This was based on the distributions for the MSPE remarks provided by the school.

 

[Matthew9Thirtyfive]

I dont know. This was based on the distributions for the MSPE remarks provided by the school.

Ah. I mean it doesn't matter really. I was just curious. It's pretty obvious that luck can play a part (who writes your evaluations, did you get a crappy resident, do you happen to click with the residents/attendings, etc.), but that only goes so far.

 

[Lawpy]

The formula for PMF is P(x;p,n) = n!/(x!(n-x)!)*(p)^x*(1-p)^(n-x), where you look at x successes in n trials, where p is the probability of success and 1-p is the probability of failure. If success is an honors and any other grade is not, then we should decide what the probability is of getting an honors. If the grading system is H/HP/P/F, then by pure chance you can assume a 0.25 chance of getting an H in any rotation and a 0.75 chance of getting anything else (again, this is chance, and studying etc have nothing to do with it). Then the probability of honoring all your rotations third year (just picking 7 to include IM, psych, FM, surgery, OB, peds, and neuro) is 7!/(7!(7-7)!)*(0.25)^7*(1-0.25)^(7-7) = 1/16384 = 6.10e-5, while the probability of honoring none of those rotations is 7!/(0!(7-0)!)*(0.25)^0*(1-0.25)^(7-0) = 0.133. So, you have a much lower chance of honoring all your rotations, but your chances of not honoring a single one is not very good either.

So the population of students who honored all or none purely by chance will be pretty small, though the people who don't honor anything will be more numerous.

But yes, my point actually is that while I'm sure luck has something to do with it, there is definitely more going on. Having 5% of your class honor every rotation means it's more than luck.

It looks like the chance of honoring no rotations is significantly greater than chance of honoring all rotations. I think pure randomness plays a major role just from this alone.

 

[Matthew9Thirtyfive]

It looks like the chance of honoring no rotations is significantly greater than chance of honoring all rotations. I think pure randomness plays a major role just from this alone.

Yeah, chance definitely has a role. But if it were purely chance you would expect 1 person in your class to honor every rotation (6.1e-5% of 171 is 1.04). Five percent of 171 is like 9 people. That's a pretty big difference, so it seems like when it comes to honoring every rotation at least, there is something else going on. Not honoring a single rotation may be more involved with random chance (you could call that bad luck).

 

[valid username]

Thank you, Libertyyne. That's very kind of you. Here's the long and drawn out version:

Do pay very close attention to your attendings. They are showing you what to do. But you don't have to push your way to front and walk with the attending to get a good grade. I know everyone has seen this little push game that occurs in every rotation. It's not necessary. The attending deserves respect, but the scramble for who can get the most attention is a waste of time and energy.

There is no need to buy him/her coffee or bring him/her baked goods. Unless that's really you. In which case it's fine.

If you are good at something, teach your colleagues. There's no need to try to be better than everyone else. Everyone is there to learn. Example:
I had a rotation where the students wrote all the scripts. The attending would point to someone and say write...and he was super picky. The first two days all my scripts had something he didn't like. So when we got new students a couple weeks into my rotation I told both "he wants you to spell all your numbers out, he wants you to write take one pill by mouth--don't write PO, etc" When the new students handed him scripts he was happy.

Conversely, when you are new to something or just suck at it, find a colleague who is good and ask for help. You can also nurses for help (Example, teaching a patient incentive spirometry). Just don't avoid doing the task. And if you are an AMG with scsttered IMGs running amok--don't make the IMGs take out all the catheters then lie about it. Nurses talk.

Nurses know a lot. However, if you ask a nurse for help make sure you honor his/her time. Ask when is a good time. Then try to do something that's not required, like taking a post-op for a walk in the hallway. Obviously, you should be teaching your own pstients IS after you've been shown. Notice everything people do for you and try to pay it back. If not, then pay it forward.

I didn't read any manuals. I have an unfair advantage. I'm older than most students. I have had jobs with major responsibilities. I have been a supervisor. I felt crowded when people tried to impress me. This has a lot to do with why I treat attendings with respect, but at a comfortable distance.

Knowing how to treat patients: again, I am older. I know what it's like to be a lay person. I also have children. One has DM1, another has a rare metabolic disease. I (or my children) have unfortunately been on the other side of the stethoscope too many times. I know how much it sucks. I know what things helped us get through. I easily understand some fears in a way that many doctors have to really work at to understand. I remember what questions sound ridiculously stupid to a lay person (for starters: is the stool foul smelling? describe the pain. do you ever hear voices?)

I also understand that some questions sound threatening. Harder to explain but 1 Example, the parent tells you they've not tried any meds. You go on to ask: tylenol? Ibuprofen? Anything? This sounds like you think the parent is hiding something--simply saying "i know you said you didn't give junior any meds, but sometimes people forget to mention over the counter things like tylenol and ibuorofen." It doesn't sound so different to you. To the parent without a medical education the difference is huge.

Obviously having given birth las an advantage when it came to OB rotations. But none of these lessons are difficult to learn if you pay attention. And if you spend some time witn patients they will help you, too.

Good luck with your clinicals. I hope you enjoy them as much as I have enjoyed mine.

 

[mcloaf]

It looks like the chance of honoring no rotations is significantly greater than chance of honoring all rotations. I think pure randomness plays a major role just from this alone.

Having the attitude that clinical evals are all luck anyway is pretty much a self-fulfilling prophecy to straight pass M3.

 

[Lawpy]

Having the attitude that clinical evals are all luck anyway is pretty much a self-fulfilling prophecy to straight pass M3.

What are your thoughts onto doing well in clinical years?

 

[mcloaf]

What are your thoughts onto doing well in clinical years?

IMO there aren't any secrets. Show up early and work hard, be a team player, offer to help however you can and take initiative. Be personable to your team and your patients. Sounds like a bunch of lame platitudes but generally it's true.

Third year is annoying and you'll need to suck up and show enthusiasm you don't feel sometimes but as long as you're not stuck with really terrible classmates on your team it's not too bad. My school weighs shelves somewhat heavily so I always made time to study a bit every day after I got home, but YMMV depending on how grades are calculated.

 

[Foot Fetish]

What is considered a heavily weighted shelf? Shelf is worth 30% at my school.

 

[Newyawk]

What is considered a heavily weighted shelf? Shelf is worth 30% at my school.

Not sure but for what it's worth my school weighs it at only 10%.

 

[mcloaf]

What is considered a heavily weighted shelf? Shelf is worth 30% at my school.

It's been a while since I reviewed the policies at my school and they vary a bit between rotations, but I believe it was generally 25-40%. Some of it's a judgment call, but considering that there is some level of clinical grading that's going to be out of your control I'm an advocate for doing what you can to optimize the factors you can influence. My attitude was that I might not have the best clinical evals on every rotation but I was always going to try to have one of the best shelf scores. I didn't honor everything but I didn't pass anything either.

Caveats to this being that if your shelf only counts for 10% of your grade maybe your study time is better spent reading up on guidelines/literature and going to bed earlier so you can get there a little earlier in the morning, or if you really suck clinically and/or have a bad attitude you're not going to honor regardless of your shelf score.

 

[valid username]

My school weighs shelves somewhat heavily so I always made time to study a bit every day after I got home, but YMMV depending on how grades are calculated.

I would add: whatever you do, make sure you study before you get home. You should ALWAYS carry something with you to study.

You will spend time in halls waiting for your attending. Make good use of this time, but avoid studing on your phone. Fair or not, many attendings judge students unfairly for studying on the phone. Think about it...when your attending goes to fill in your evaluation which image do you want to pop up...your nose in your phone, or your nose in a book? It's not fair, but you can't change it. Pre-test books fit in your white coat pocket.

A bonus to studying from a book:it easily becomes a group activity. This is most noticeable in surgery and OB. Those moments when you have to wait can easily become impromptu study sessions. You may be surprised to see how often doctors weigh in on your discussions. In case this is not obvious, I am talking about your inpatient portions. In my experience, it was very easy to recall these discussions when taking my shelf exams.

Try to treat every shelf exam as a very big deal no matter the percent. You will be glad you took them seriously when it's time to take Step2.