Hi everyone. I am doing my clinical rotations, and I have some questions. I just don't have anyone to ask these random questions too...
Does anyone worry that they are just regurgitating info on rounds? i feel like if im not admitting someone, i dont feel like im being original in making the daily plan for patients. like, when i get to admit someone i have the chance to see the patient alone, write the H&P note, and think through the differential and plan. however, when i pick up patients to follow day-to-day, i feel like the plan is already set and there arent that many changes... so me presenting is basically just reciting what is in the EMR already. Idk.. does anyone feel this?
any tips for maximizing learning? im just worried about not being ale to create the plans on my own.. idk
Read the Clinical Rotations Guide on my signature. It's not mine, but I think it's good. I can provide help for what can be done from internal medicine perspective. OB/GYN, Peds, etc. will be different and hopefully other residents will advise about those.
First let me validate all your concerns by saying this is exactly how I felt. Plans would be made and it felt I was just being explained them. Things were happening behind the scenes on my patient I was not privy too. There's stuff I easily could have been made aware about, but the resident decided to keep it to him/herself until the presentation when they corrected me. Unfortunately the role of the medical student on clinical rotations is shrinking so you need to be able to capitalize on the experiences you do have. At many hospitals as a medical student, your admission may truly not be yours. This is due to a compilation of factors including your own understanding, residents anal-retentive nature, the busyness of the service, and cultural expectations of students.
1.) Deliberate practice on your own. Create a OneNote page where you outline your own work-ups to common problems like anemia, HTN, etc. Don't rely on the algorithms of others, but organize it in a way you think. Obviously there's going to be some things that are going to make sense like separating metabolic acidosis by anion gap or separating anemia by MCV but create of compilation. Focus on one area (anemia, HTN, etc.) per day and by the end of the year you will have amassed a large collection. Take the residents help but don't rely on them to create your system. If you really like a table here or there, steal it with the capture feature on put it in your OneNote.
2.) Be 100% available. Never do UWorld/Read after rounds. You can do that once you're dismissed. There's always something you can be doing for your patient. First make sure you follow up on labs/consults. If you did that, you can see if the attending has signed the note and added any changes. If you did that, you can anticipate what needs to be done for the patient later and if the patient is on the schedule. If they're getting discharged soon, are the summary, medical reconciliation, and patient instructions ready? If not do them (but don't overpredict or else you'll end up redoing work). Has case management been updated on this patient today? If not ask if you can do that. If you have that done, you can go have a chat with the patient and answer questions (without creating confusion with the team). If you've done that, you can update signout on your patient. This will not improve your clinical reasoning, BUT I just listed every possible aspect of patient care the resident is thinking about. There's a disparity because oftentimes the medical student's not aware this is all in the resident's head. If you have this in your head, less will get by you and the resident will truly realize you really understand what's going on with your patient.
3. Get efficient with your notes. Use a template. Don't make it too different from the templates residents use (hospital systems prefer if you use their template instead of being a deviant and creating everything on your own - for billing). If you have to write a note on a patient, do these things:
Pre-chart before you go to bed. Start your note based on the data you have. Careful...you need to refresh the autopopulated stuff tomorrow before signing it. Use the same visual cues. In my notes, bolded means the result is still pending. Underlined means this is something for me to follow up on today. Organization of this works differently for everyone (for example you can make a follow up/pending line in your to-do list) but have an efficient symptom as it will make your notes faster so you can write your own.
#Meningitis:
#Altered Mental Status:
CSF studies and clinical presentation consistent with meningitis, differential includes Fungal vs. Viral, less likely bacterial.
Admission Tm-39.6, no focal deficits, CSF differential consistent with meningitis
CSF diff: glycorrhea, lymphocytosis, high opening pressure, follow up CSF culture
Blood Cultures NG1D,
Pending:
Cryptococcal Ag, Viral CSF, Fungal Battery.
-Appreciate ID recommendations
-Follow up Neurosurgery recommendations
-Ceftriaxone 4/19- , Amphotericin 4/20- , Vancomycin - 4/19, Fluconazole 4/20-
-Monitor Blood Cultures and CSF studies.
4. Maybe this is controversial but don't stress too much about the presentation. You've done the work. Come up with a reliable way to present it verbally. The following applies to medicine only (surgery is different) but as a medical student no one is going to fault you for reading off of your note especially as an M3. If you choose to do that, be very judicious about what you choose to say or not say. Only state the main points of the HPI that relate to your differential, only very abnormal ROS should be mentioned. The physical exam shouldn't be presented as "Vital signs ***, patient appeared ***, abnormal findings noted on exam were ***, move on. For labs, comment on the BMP, CBC, UA/Cardiac if applicable, and then anything relevant to the case. Mention that you reviewed EKG/Imaging/Culture data and that abnormal findings were ***. Then say in summary this is a 67M patient with medical history of HIV, IVDU brought to the hospital by family for altered mental status and fever in the setting of immediate clinical evidence suggestive of meningitis. Other considerations regarding the meningitis include *** then go right into the plan. This part should take the longest. Make sure you can in that order. If you find yourself going into the plan in the history...stop yourself, verbalize that you'll get to that later, and then move on.
5. Even if you do all these things, you will still lack the anticipation and efficiency of a resident and will miss things. Be humble. There will be things you didn't think of that the residents did. Never try to outshine anyone. Just do your best and your team will appreciate your work as they were in your position and know what you know or don't know.
Thanks so much for asking this question. Love answering these. Best of luck!
