How to not look like an incompetent fool on rotations?

[munchymanRX]

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Namely, are there any skills (suturing, intubation, etc) that I should be brushing up on prior to 3rd year clerkships? Many of the students ahead of me have stories of being berated for their lack of skill in certain techniques-is there anything in particular SDN recommends?

 

[silas2642]

Know your patient inside and out. Read about their diseases when you can.

 

[DrSnips]

Namely, are there any skills (suturing, intubation, etc) that I should be brushing up on prior to 3rd year clerkships? Many of the students ahead of me have stories of being berated for their lack of skill in certain techniques-is there anything in particular SDN recommends?

Practicing suturing might help you get yelled at less on surgery, but I doubt you will be asked to intubate anyone unless you specifically request a chance.

Reading about your patients' conditions takes priority when you have downtime -- uptodate is good enough for this. If you really want to shine, read about the management of conditions that are really common on the wards so you'll look informed when they invariably show up. Just to name a few, CHF, ACS / MI, DM, DVT / PE, asthma / COPD, cellulitis / osteomyelitis and HIV are all good topics for IM wards, and by knowing about them you may be able to spare yourself the feared consequence of not knowing pimp questions, i.e. "Why don't you give us a presentation on that tomorrow?"

 

[duckie99]

There is no one particular skill that will be expected of a M3, especially when first starting. The only hand skill I recommend is reviewing how to tie a knot in surgery.

Otherwise for every single rotation just be prepared to present patients on rounds and learn to write concise and accurate patient notes. These are two major skills that are critical to develop early. It is also the only way to really demonstrate to anyone that you know what you are doing (no one will really expect that you do however...). Every field has its quirks about how and what to present so I highly suggest discussing with the lowest level person on the team (M4, intern, etc) the best way to present patients and what info the attendings want to know. Also be sure to go in a set order every time and stay on track as much as possible. Presenting is a skill and takes some time to get better at. I have met plenty of M4s who think they are good and try to memorize stuff only to see it really fall flat so don't be that type of person. Write down the info, try and know it as much as possible, and present (i.e. do not read your notes).

Regarding pimp questions; you will not get a lot of them right. Learn to live with that. You will be forced to do presentations on topics pretty often. These are not punishments but learning exercises. The presentations are usually only about 5 minutes and usually is a good review for the residents as well (they probably don't know as much as you think they do...).

 

[survivordo]

Skills required for third year: be there on time, be interested, don't whine, know your patients. If all students would do just these simple things they would be alright.

Survivor DO

 

[Stellar Clouds]

Skills required for third year: be there on time, be interested, don't whine, know your patients. If all students would do just these simple things they would be alright.

Survivor DO

I would also include: don't ask to go home.

 

[Laryngophed]

Know your patient inside and out. Read about their diseases when you can.

This. No one can ever fault you for knowing your patient's H&P. Any additional knowledge about pathophys and treatments will icing on the cake.

As for skills, learn to hand-tie in suturing is the only thing that I think may make you a little more impressive. Master the two hand tie. As for where to place the needle, that is something that I always ask my resident which stitch they want, and if I don't know them I ask them for help.

Don't worry. You are going to start third year, no one expects you to be good at anything other than reading.

 

[shan564]

You will look like an incompetent fool no matter what.

One of the biggest things is to remember that you're there to learn. Don't be arrogant, and be excited about learning. If you don't know something, don't pretend like you know it.

 

[VisionaryTics]

You will look like an incompetent fool no matter what.

👍👍

Attendings expect you to work on your basic medical knowledge (that means read a lot), your H&Ps (be thorough), and your presentation skills.

Beyond that, come up with an assessment and plan for EVERY patient, on your own if you can. It's the best way to develop your diagnostic/management skills.

 

[mvenus929]

Best advice: Go through the flow of an H&P, do a couple practice presentations so you get used to the flow. Yes, when you're on surgery/OB, you should practice knot tying in your spare time (though I did very little knot tying, since most of our closing stitches were sub-Q). But you should be taught these things first. If you already know how to do them, then practicing a little won't hurt you, but the bread and butter for 3rd year students on the wards is presentations.

Practicing some physical exam things, like heart, lung, abdomen exam, and reflexes, certainly doesn't hurt.

 

[NickNaylor]

👍👍

Attendings expect you to work on your basic medical knowledge (that means read a lot), your H&Ps (be thorough), and your presentation skills.

Beyond that, come up with an assessment and plan for EVERY patient, on your own if you can. It's the best way to develop your diagnostic/management skills.

I find that my ability to come up with an A&P is pretty much zero without taking "hints" from notes by attendings/residents that have already seen the patient. I'm sure this is a broad question, but any tips here? Is it just as simple as coming up with a reasonable differential and UpToDate does the rest?

 

[Laryngophed]

I find that my ability to come up with an A&P is pretty much zero without taking "hints" from notes by attendings/residents that have already seen the patient. I'm sure this is a broad question, but any tips here? Is it just as simple as coming up with a reasonable differential and UpToDate does the rest?

One of our surgeons gave me simple advice that really focused it for me. "Pretend like you are the only person taking care of that patient, think about each problem and how you would address each one. Then make sure you don't create more (unnecessary) problems with your management." I felt like an idiot because I was way over-thinking the A&P, but that's really all you have to do. Sure, I'm wrong frequently. But I take a shot, then either compare my plan to the someone up the chain on my own, or ask them how to optimize my plan.

 

[VisionaryTics]

I find that my ability to come up with an A&P is pretty much zero without taking "hints" from notes by attendings/residents that have already seen the patient. I'm sure this is a broad question, but any tips here? Is it just as simple as coming up with a reasonable differential and UpToDate does the rest?

It'll come. Yeah, use UpToDate, your pocket book du jour, etc. This is where reading a ton really comes in handy: you should know the basic workup/treatment for the common problems on your particular rotation.

On family medicine, no one is going to expect you to know how to manage insulin regimens and multi-drug therapy of diabetes, but you should be able to say: "This is a 55 year old gentleman with HTN, HL, and DM with an A1c of 9.5 on metformin. We should consider adding insulin to his regimen and write referrals for ophtho/podiatry."

 

[NickNaylor]

One of our surgeons gave me simple advice that really focused it for me. "Pretend like you are the only person taking care of that patient, think about each problem and how you would address each one. Then make sure you don't create more (unnecessary) problems with your management." I felt like an idiot because I was way over-thinking the A&P, but that's really all you have to do. Sure, I'm wrong frequently. But I take a shot, then either compare my plan to the someone up the chain on my own, or ask them how to optimize my plan.

I feel like that's exactly what's happening. I like to be thorough and try and explain/justify as much as I can, which has been leading to lengthy A&Ps that, as you mention, seem to open the door for even more problems. On the other hand, I'm fearful of short A&Ps because I might come across as having "not considered everything." It seems like there's a balance to be struck and I'm just not finding it.

It'll come. Yeah, use UpToDate, your pocket book du jour, etc. This is where reading a ton really comes in handy: you should know the basic workup/treatment for the common problems on your particular rotation.

On family medicine, no one is going to expect you to know how to manage insulin regimens and multi-drug therapy of diabetes, but you should be able to say: "This is a 55 year old gentleman with HTN, HL, and DM with an A1c of 9.5 on metformin. We should consider adding insulin to his regimen and write referrals for ophtho/podiatry."

That seems entirely reasonable and is probably the best that I could up with given by nearing-completion-of-MS2 level of knowledge. We do write-ups in the context of doing H&Ps on patients and reporting findings, any lab/test results, etc., so I'm missing a bunch of clinical knowledge which I would expect, but sometimes I feel like a complete idiot with what our preceptors for this thing expect us to know. I mean it's stuff that I never would've even thought to look up or research. I can't tell if I'm deficient in knowledge or if these attendings are a bit demanding.

 

[VisionaryTics]

On the other hand, I'm fearful of short A&Ps because I might come across as having "not considered everything." It seems like there's a balance to be struck and I'm just not finding it.

Here's the trick: be able to rule in/rule out the scary stuff, and then argue for your most likely diagnosis (or two).

Example: Chest pain. Argue why it's not ACS, PE, or dissection, then argue for chostochondritis or GERD or whatever.

If you do that, you have just demonstrated that you 1) came up with a differential, 2) argued for a specific diagnosis which leads to 3) a specific treatment plan. That's top notch work for M3s, as far as attendings are concerned.

Don't be concerned if you aren't getting it as an M2. Studying for Step 1 really helps tie things together across disciplines, and the only way to really get better at this stuff is to do it over and over again (which you get plenty of in M3).

 

[DreamingTheLive]

At some point, its unavoidable. More importantly, how will you react?

 

[WiseGuy1]

I find that my ability to come up with an A&P is pretty much zero without taking "hints" from notes by attendings/residents that have already seen the patient. I'm sure this is a broad question, but any tips here? Is it just as simple as coming up with a reasonable differential and UpToDate does the rest?

This isn't great advice, but this will come, eventually. You probably won't ever have an epiphany and it probably won't click instantly, but one day you'll realize you know this. It will come naturally.

 

[mmmcdowe]

Practicing suturing is great, but if you really want to impress practice cutting the suture the right length

 

[VisionaryTics]

Practicing suturing is great, but if you really want to impress practice cutting the suture the right length

There are only two lengths: too long or too short. There is no right length. If there were, it is still impossible to achieve it while craning your hand eight feet across a surgical field to cut sutures you can barely see.

 

[Laryngophed]

Practicing suturing is great, but if you really want to impress practice cutting the suture the right length

Impossible. When you wear the short coat you are only able to cut the tails too long and too short. You are free to provide the option to the surgeon prior to cutting, but I'd recommend ducking.

 

[mimelim]

I just did evals for our medical students from February. Supposedly the clerkship director will edit/review them, but I kinda doubt it since what I wrote will be more detailed than he could ever write based on his interaction with them which was minimal.

I will only talk about surgery clerkships since that is what I know. A lot of this will apply to other clerkships that others can adapt. I can give specific examples for every single number below based on last month alone. These are very common issues.

To avoid being a bad student:
1) Show up on time
2) Look professional
3) Be available. You should never disapear and unreachable.
4) If asked to do something, either say, "Yes, I'll do it" or, "I don't feel comfortable with that, do you mind teaching me how to do it so I can do it next time?"
5) Do not ask "Anything that I can do right now?", ask, "How can I help?" or simply offer to do things, I hate scutting stuff to students, but if you offer to drop my notes off for me, or you feel comfortable finishing a dressing change on your own, if you say, "I can handle this" or just "I got this".

To be a good student:
1) Know your patients inside out and backwards. You are carrying less patients than your residents/attendings, you should know the details about your patient, even if they don't. You may not know what it means, but you should have the info available.
2) Always make an assessment, attempt to develop a plan. Start with a wide differential and focus in on the most likely diagnoses.
3) Read. Every night, even if it is for 15 minutes. Read about your patient or the procedure they are about to have or have had.
4) Be helpful. Getting labs, dropping notes in charts etc. Scut sucks, we all have to do it.
5) Tie and suture. I will walk anyone through how to do something, but I expect you to know the basics before showing up in the OR. If I show you how to do something, you should practice it at home and if you don't get it, ask me to show you again when we have down time.

To be a rock star:
1) Know your patients inside and out, but pay attention to what residents and attendings find important. Nobody will fault an MS3 for giving a laundry list of normal physical exam findings/labs, but eventually you have to learn to focus in on the important things so you can effectively communicate with colleagues down the road.
2) Develop skills. You are as useful as the skills that you posess. Things that an MS3 could potentially know how to do solo or with only resident observation:
a) Wet to dry dressings
b) Wound vac exchanges
c) Chest tube placements
d) Chest tube removals
e) Suturing - Simple, horizontal matress, vertical matress, sub Q, deep dermal, running
f) Central line placement
g) Central line removal
h) Fever workup
i) Getting outside hospital records
3) Learn to solve the common problems. Every rotation, go to the charge nurse on your main floor and ask them what the 10 most common intern calls are for. They should sound like this: Pain, fever, nausea, tachycardia, hypertension, electrolyte abnormalities etc. And then the specifics, Vascular: loss of previously dopplerable pulse, Gen Surg: change in abdominal exam findings etc. Then learn how to work up or manage those issues. As an MS4 on sub-I a good student will function like an intern. Those skills don't show up overnight, you have to develop them over time starting as an MS3.
4) Do not stop suturing or knot tieing. If you are interested in surgery, innate ability counts for something, but more important is practice. You should be able to do one handed ties left and right handed with ease. You should be efficient and accurate. When in conference, tie to your scrub bottoms or the chair next to you. If you have down time, have someone check your technique.
5) Think before cutting suture. What kind of suture are you cutting? Where are you cutting it? What is the purpose of this stitch? How many knots were tied? There is a logic behind suture tail length. While you will always have people that do things a particular way "just because", the vast majority will have a method behind their madness.

 

[Laryngophed]

I would do some unsavory things to be able to place chest tubes and central lines on a regular basis at our house. It seems (from my limited perspective) that because we have so few procedures to go around, we are last in line. A few of the upper-level surgical residents will let students do them, but they are the exception.

Bummer.

 

[tiedyeddog]

I just did evals for our medical students from February. Supposedly the clerkship director will edit/review them, but I kinda doubt it since what I wrote will be more detailed than he could ever write based on his interaction with them which was minimal.

I will only talk about surgery clerkships since that is what I know. A lot of this will apply to other clerkships that others can adapt. I can give specific examples for every single number below based on last month alone. These are very common issues.

To avoid being a bad student:
1) Show up on time
2) Look professional
3) Be available. You should never disapear and unreachable.
4) If asked to do something, either say, "Yes, I'll do it" or, "I don't feel comfortable with that, do you mind teaching me how to do it so I can do it next time?"
5) Do not ask if there is anything to

To be a good student:
1) Know your patients inside out and backwards. You are carrying less patients than your residents/attendings, you should know the details about your patient, even if they don't. You may not know what it means, but you should have the info available.
2) Always make an assessment, attempt to develop a plan. Start with a wide differential and focus in on the most likely diagnoses.
3) Read. Every night, even if it is for 15 minutes. Read about your patient or the procedure they are about to have or have had.
4) Be helpful. Getting labs, dropping notes in charts etc. Scut sucks, we all have to do it.
5) Tie and suture. I will walk anyone through how to do something, but I expect you to know the basics before showing up in the OR. If I show you how to do something, you should practice it at home and if you don't get it, ask me to show you again when we have down time.

To be a rock star:
1) Know your patients inside and out, but pay attention to what residents and attendings find important. Nobody will fault an MS3 for giving a laundry list of normal physical exam findings/labs, but eventually you have to learn to focus in on the important things so you can effectively communicate with colleagues down the road.
2) Develop skills. You are as useful as the skills that you posess. Things that an MS3 could potentially know how to do solo or with only resident observation:
a) Wet to dry dressings
b) Wound vac exchanges
c) Chest tube placements
d) Chest tube removals
e) Suturing - Simple, horizontal matress, vertical matress, sub Q, deep dermal, running
f) Central line placement
g) Central line removal
h) Fever workup
i) Getting outside hospital records
3) Learn to solve the common problems. Every rotation, go to the charge nurse on your main floor and ask them what the 10 most common intern calls are for. They should sound like this: Pain, fever, nausea, tachycardia, hypertension, electrolyte abnormalities etc. And then the specifics, Vascular: loss of previously dopplerable pulse, Gen Surg: change in abdominal exam findings etc. Then learn how to work up or manage those issues. As an MS4 on sub-I a good student will function like an intern. Those skills don't show up overnight, you have to develop them over time starting as an MS3.
4) Do not stop suturing or knot tieing. If you are interested in surgery, innate ability counts for something, but more important is practice. You should be able to do one handed ties left and right handed with ease. You should be efficient and accurate. When in conference, tie to your scrub bottoms or the chair next to you. If you have down time, have someone check your technique.
5) Think before cutting suture. What kind of suture are you cutting? Where are you cutting it? What is the purpose of this stitch? How many knots were tied? There is a logic behind suture tail length. While you will always have people that do things a particular way "just because", the vast majority will have a method behind their madness.

Thanks for this, very helpful!

What should we do instead of asking if there is anything to do? Just stand around silently??

 

[Laryngophed]

Thanks for this, very helpful!

What should we do instead of asking if there is anything to do? Just stand around silently??

You ask the question this way "What can I do to make your life easier/help the team/help you out?

Residents will love you for it. And they will often reward you for doing a bit of scut. I've gotten to be more involved in procedures or alternatively sent home early if there were no activities planned later in the day because I try to make my residents' lives easier.

Edit: Remember Rule #11.

 

[KinasePro]

The more "scut" you do, the more time the residents will have to teach you cool ****. If you make their lives easier, they will repay you (usually).

 

[mimelim]

You ask the question this way "What can I do to make your life easier/help the team/help you out?

Residents will love you for it. And they will often reward you for doing a bit of scut. I've gotten to be more involved in procedures or alternatively sent home early if there were no activities planned later in the day because I try to make my residents' lives easier.

Edit: Remember Rule #11.

What he said, also, I updated the original post.

 

[tiedyeddog]

You ask the question this way "What can I do to make your life easier/help the team/help you out?

Residents will love you for it. And they will often reward you for doing a bit of scut. I've gotten to be more involved in procedures or alternatively sent home early if there were no activities planned later in the day because I try to make my residents' lives easier.

Edit: Remember Rule #11.

The more "scut" you do, the more time the residents will have to teach you cool ****. If you make their lives easier, they will repay you (usually).

What he said, also, I updated the original post.

Thanks, you all are awesome.

 

[mvenus929]

I feel like that's exactly what's happening. I like to be thorough and try and explain/justify as much as I can, which has been leading to lengthy A&Ps that, as you mention, seem to open the door for even more problems. On the other hand, I'm fearful of short A&Ps because I might come across as having "not considered everything." It seems like there's a balance to be struck and I'm just not finding it.

When I really started doing A/Ps, I found it really helpful to go by system. It's not required in notes unless you're in ICU, but it's helpful to make sure you've covered everything. For instance:

1) Neuro: Pain control. Nausea. Do they have any specific neuro issues that need to be addressed?
2) Cardio: do you need to start or stop their home beta-blockers/aspirin/lisinopril? Do they need monitoring? Are you trending troponins?
3) Respiratory: Do they need to be on oxygen? Are they on a ventilator? Do we need to get rid of some of their pulmonary edema? Do they need incentive spirometry? Can they get out of bed?
4) FEN (fluid, electrolytes, nutrition)/GI: Do they have prophylaxis for stress ulcers? What sort of fluids do they need and how much? Do they need any electrolyte replacement? Are they NPO, and if not, what sort of diet can they have? Are they making adequate urine, and if not, how can you correct that? Are they making stool, and if not, how can you correct that?
5) Heme: Do they need blood? Do they need FFP/platelets? Some people will also put DVT prophylaxis here.
6) ID: Do they need any antibiotics? If they spike a fever, what will you do?
7) Endo: Do they need insulin? Do they need blood glucose monitoring (how often)? Are they on any endo medications that need to be continued/stopped?
8) MSK: Are there any issues here? How will you address them?
9) Other: depending on your patient, you might need a skin section, or a psych section. Just figure out what their main complaint is, and if it doesn't fit into the above categories, make another.

This can also be helpful figuring out a differential. If they have chest pain, it could be cardio, resp, or MSK, and you should come up with ways to distinguish between them, if it's not clear by physical exam alone.

Also, it's okay to be wrong. Even the residents get corrected by the attending when they present their plan. That's why you're on the wards. In an ideal situation, the residents will go over your plan and hopefully get you to think through it more before you present to the attending.

 

[Cali2]

To be a rock star:
1) Know your patients inside and out, but pay attention to what residents and attendings find important. Nobody will fault an MS3 for giving a laundry list of normal physical exam findings/labs, but eventually you have to learn to focus in on the important things so you can effectively communicate with colleagues down the road.
2) Develop skills. You are as useful as the skills that you posess. Things that an MS3 could potentially know how to do solo or with only resident observation:
a) Wet to dry dressings
b) Wound vac exchanges
c) Chest tube placements
d) Chest tube removals
e) Suturing - Simple, horizontal matress, vertical matress, sub Q, deep dermal, running
f) Central line placement
g) Central line removal
h) Fever workup
i) Getting outside hospital records
3) Learn to solve the common problems. Every rotation, go to the charge nurse on your main floor and ask them what the 10 most common intern calls are for. They should sound like this: Pain, fever, nausea, tachycardia, hypertension, electrolyte abnormalities etc. And then the specifics, Vascular: loss of previously dopplerable pulse, Gen Surg: change in abdominal exam findings etc. Then learn how to work up or manage those issues. As an MS4 on sub-I a good student will function like an intern. Those skills don't show up overnight, you have to develop them over time starting as an MS3.
4) Do not stop suturing or knot tieing. If you are interested in surgery, innate ability counts for something, but more important is practice. You should be able to do one handed ties left and right handed with ease. You should be efficient and accurate. When in conference, tie to your scrub bottoms or the chair next to you. If you have down time, have someone check your technique.
5) Think before cutting suture. What kind of suture are you cutting? Where are you cutting it? What is the purpose of this stitch? How many knots were tied? There is a logic behind suture tail length. While you will always have people that do things a particular way "just because", the vast majority will have a method behind their madness.

A lot of this is great, but there is no way a MS3 should be doing chest tubes or central lines alone...

 

[mimelim]

A lot of this is great, but there is no way a MS3 should be doing chest tubes or central lines alone...

They shouldn't be doing them alone. But, it isn't much of a stretch to say that they should be able to do it alone/without guidance. I had 15 subclavians before I left medical school and more than 6 femorals and IJs. The first day of residency, if someone asked me to throw in a line, I would not have hesitated.

 

[link2swim06]

They shouldn't be doing them alone. But, it isn't much of a stretch to say that they should be able to do it alone/without guidance. I had 15 subclavians before I left medical school and more than 6 femorals and IJs. The first day of residency, if someone asked me to throw in a line, I would not have hesitated.

Dam that is awesome, did you do that M3 or M4 year?

I am finishing up M3 year and have certainly done a handful of procedures (from delivering babies to intubating to suturing) but nothing like you had done.

Hell, I have only seen/practice a central line on a manikin two or three times.



To the OP, to look like a good med student you need to know everything about your patients. EVERYTHING. You will get asked by residents/attendings what the status consult or has the pt had a bowel movement. You need to know this off the top of your head.

Also don't just present the H&P. At least attempt to come up with a plan. For this Uptodate is your friend. Suggest your 'top 3' differential, the needed lab work to finalize the diagnosis and then the most common treatments.

 

[mimelim]

Dam that is awesome, did you do that M3 or M4 year?

I am finishing up M3 year and have certainly done a handful of procedures (from delivering babies to intubating to suturing) but nothing like you had done.

Hell, I have only seen/practice a central line on a manikin two or three times.

Product of circumstance. I did 2 months of trauma and a month of trauma ICU between M3 and M4, and then another month of SICU and 3 months of Vascular. Thats 7 months of rotations where you do a ton of central lines. It helps to be at a true trauma hospital. In contrast, I intubated a manikin maybe 4-5 times and never a real person.

Last month alone as an intern on a general/vascular service I logged 30+ central lines between floor lines and tunnelled dialysis catheters. Purely a product of where you are and what they do on that service.

 

[evilbooyaa]

Good lord, I couldn't imagine being allowed to place a chest tube or a central line as a MS3. ALl the residents at my institution are reaching their required limits on things like that. Extent of things I've been allowed to do is intubate and place IVs (only on Anesthesia sub block). Besides that, it's been skin suturing and maybe holding the camera.

 

[tobi44]

I just did evals for our medical students from February. Supposedly the clerkship director will edit/review them, but I kinda doubt it since what I wrote will be more detailed than he could ever write based on his interaction with them which was minimal.

I will only talk about surgery clerkships since that is what I know. A lot of this will apply to other clerkships that others can adapt. I can give specific examples for every single number below based on last month alone. These are very common issues.

To avoid being a bad student:
1) Show up on time
2) Look professional
3) Be available. You should never disapear and unreachable.
4) If asked to do something, either say, "Yes, I'll do it" or, "I don't feel comfortable with that, do you mind teaching me how to do it so I can do it next time?"
5) Do not ask "Anything that I can do right now?", ask, "How can I help?" or simply offer to do things, I hate scutting stuff to students, but if you offer to drop my notes off for me, or you feel comfortable finishing a dressing change on your own, if you say, "I can handle this" or just "I got this".

To be a good student:
1) Know your patients inside out and backwards. You are carrying less patients than your residents/attendings, you should know the details about your patient, even if they don't. You may not know what it means, but you should have the info available.
2) Always make an assessment, attempt to develop a plan. Start with a wide differential and focus in on the most likely diagnoses.
3) Read. Every night, even if it is for 15 minutes. Read about your patient or the procedure they are about to have or have had.
4) Be helpful. Getting labs, dropping notes in charts etc. Scut sucks, we all have to do it.
5) Tie and suture. I will walk anyone through how to do something, but I expect you to know the basics before showing up in the OR. If I show you how to do something, you should practice it at home and if you don't get it, ask me to show you again when we have down time.

To be a rock star:
1) Know your patients inside and out, but pay attention to what residents and attendings find important. Nobody will fault an MS3 for giving a laundry list of normal physical exam findings/labs, but eventually you have to learn to focus in on the important things so you can effectively communicate with colleagues down the road.
2) Develop skills. You are as useful as the skills that you posess. Things that an MS3 could potentially know how to do solo or with only resident observation:
a) Wet to dry dressings
b) Wound vac exchanges
c) Chest tube placements
d) Chest tube removals
e) Suturing - Simple, horizontal matress, vertical matress, sub Q, deep dermal, running
f) Central line placement
g) Central line removal
h) Fever workup
i) Getting outside hospital records
3) Learn to solve the common problems. Every rotation, go to the charge nurse on your main floor and ask them what the 10 most common intern calls are for. They should sound like this: Pain, fever, nausea, tachycardia, hypertension, electrolyte abnormalities etc. And then the specifics, Vascular: loss of previously dopplerable pulse, Gen Surg: change in abdominal exam findings etc. Then learn how to work up or manage those issues. As an MS4 on sub-I a good student will function like an intern. Those skills don't show up overnight, you have to develop them over time starting as an MS3.
4) Do not stop suturing or knot tieing. If you are interested in surgery, innate ability counts for something, but more important is practice. You should be able to do one handed ties left and right handed with ease. You should be efficient and accurate. When in conference, tie to your scrub bottoms or the chair next to you. If you have down time, have someone check your technique.
5) Think before cutting suture. What kind of suture are you cutting? Where are you cutting it? What is the purpose of this stitch? How many knots were tied? There is a logic behind suture tail length. While you will always have people that do things a particular way "just because", the vast majority will have a method behind their madness.

Two questions....what are "intern calls"? And will the nurse know the "specifics" or do I need to figure that out?

 

[mimelim]

Two questions....what are "intern calls"? And will the nurse know the "specifics" or do I need to figure that out?

Intern calls are what interns get called about. For example, if you are following Mr. Smith in the hospital and the nurse for Mr. Smith calls you and says,

"Doctor, Mr. Smith has a fever of 102.3, what do you want me to do?"
"Doctor, The lab just called, Mr. Smith has a potassium of 7.4."

Or specifics for a service:

"Doctor, Mr. Smith lost his DP signal since we last checked 4 hours ago."


What do you do if that happens? If you are an MS3, in a year or two, you will have to answer those questions. It is your job to answer those questions and take care of patients. The interns that stand out are the ones that can do that without being hand held because they have already been thinking about how to be useful BEFORE they HAVE to do it.

 

[chemsmith]

I would do some unsavory things to be able to place chest tubes and central lines on a regular basis at our house. It seems (from my limited perspective) that because we have so few procedures to go around, we are last in line. A few of the upper-level surgical residents will let students do them, but they are the exception.

Bummer.

fellatio?

 

[Charles_Carmichael]

I find that my ability to come up with an A&P is pretty much zero without taking "hints" from notes by attendings/residents that have already seen the patient. I'm sure this is a broad question, but any tips here? Is it just as simple as coming up with a reasonable differential and UpToDate does the rest?

Hey Nick, throughout my school's practicum, I've been using this book called "Symptom to Diagnosis" and it's been excellent:

http://www.amazon.com/Symptom-Diagn...68291474&sr=8-1&keywords=symptom+to+diagnosis

Each chapter is devoted to one chief complaint and it walks you through case studies. I found it really useful for organizing how I approach different chief complaints in my head -- it does a good job there, so that I can reason my way through differentials instead of memorizing lists. It's made presenting and coming up with A&Ps much easier. Check it out if you're interested; I haven't read the whole thing, but just the common complaints I see on the IM wards. If your school has a subscription to AccessMedicine, you can read it for free on that site.

 

[Freddie Mercury]

I just did evals for our medical students from February. Supposedly the clerkship director will edit/review them, but I kinda doubt it since what I wrote will be more detailed than he could ever write based on his interaction with them which was minimal.

I will only talk about surgery clerkships since that is what I know. A lot of this will apply to other clerkships that others can adapt. I can give specific examples for every single number below based on last month alone. These are very common issues.

To avoid being a bad student:
1) Show up on time
2) Look professional
3) Be available. You should never disapear and unreachable.
4) If asked to do something, either say, "Yes, I'll do it" or, "I don't feel comfortable with that, do you mind teaching me how to do it so I can do it next time?"
5) Do not ask "Anything that I can do right now?", ask, "How can I help?" or simply offer to do things, I hate scutting stuff to students, but if you offer to drop my notes off for me, or you feel comfortable finishing a dressing change on your own, if you say, "I can handle this" or just "I got this".

To be a good student:
1) Know your patients inside out and backwards. You are carrying less patients than your residents/attendings, you should know the details about your patient, even if they don't. You may not know what it means, but you should have the info available.
2) Always make an assessment, attempt to develop a plan. Start with a wide differential and focus in on the most likely diagnoses.
3) Read. Every night, even if it is for 15 minutes. Read about your patient or the procedure they are about to have or have had.
4) Be helpful. Getting labs, dropping notes in charts etc. Scut sucks, we all have to do it.
5) Tie and suture. I will walk anyone through how to do something, but I expect you to know the basics before showing up in the OR. If I show you how to do something, you should practice it at home and if you don't get it, ask me to show you again when we have down time.

To be a rock star:
1) Know your patients inside and out, but pay attention to what residents and attendings find important. Nobody will fault an MS3 for giving a laundry list of normal physical exam findings/labs, but eventually you have to learn to focus in on the important things so you can effectively communicate with colleagues down the road.
2) Develop skills. You are as useful as the skills that you posess. Things that an MS3 could potentially know how to do solo or with only resident observation:
a) Wet to dry dressings
b) Wound vac exchanges
c) Chest tube placements
d) Chest tube removals
e) Suturing - Simple, horizontal matress, vertical matress, sub Q, deep dermal, running
f) Central line placement
g) Central line removal
h) Fever workup
i) Getting outside hospital records
3) Learn to solve the common problems. Every rotation, go to the charge nurse on your main floor and ask them what the 10 most common intern calls are for. They should sound like this: Pain, fever, nausea, tachycardia, hypertension, electrolyte abnormalities etc. And then the specifics, Vascular: loss of previously dopplerable pulse, Gen Surg: change in abdominal exam findings etc. Then learn how to work up or manage those issues. As an MS4 on sub-I a good student will function like an intern. Those skills don't show up overnight, you have to develop them over time starting as an MS3.
4) Do not stop suturing or knot tieing. If you are interested in surgery, innate ability counts for something, but more important is practice. You should be able to do one handed ties left and right handed with ease. You should be efficient and accurate. When in conference, tie to your scrub bottoms or the chair next to you. If you have down time, have someone check your technique.
5) Think before cutting suture. What kind of suture are you cutting? Where are you cutting it? What is the purpose of this stitch? How many knots were tied? There is a logic behind suture tail length. While you will always have people that do things a particular way "just because", the vast majority will have a method behind their madness.

Thank you, saving for future reference.

 

[tobi44]

Intern calls are what interns get called about. For example, if you are following Mr. Smith in the hospital and the nurse for Mr. Smith calls you and says,

"Doctor, Mr. Smith has a fever of 102.3, what do you want me to do?"
"Doctor, The lab just called, Mr. Smith has a potassium of 7.4."

Or specifics for a service:

"Doctor, Mr. Smith lost his DP signal since we last checked 4 hours ago."


What do you do if that happens? If you are an MS3, in a year or two, you will have to answer those questions. It is your job to answer those questions and take care of patients. The interns that stand out are the ones that can do that without being hand held because they have already been thinking about how to be useful BEFORE they HAVE to do it.

Oh ok that makes sense. I'll make sure to do that. One more thing, my first rotation is family medicine in a small practice, outpatient. Can you think of anyway that I specifically prep for this?

And thank you! Btw, I find most of your posts to be really useful.

 

[Stellar Clouds]

Oh ok that makes sense. I'll make sure to do that. One more thing, my first rotation is family medicine in a small practice, outpatient. Can you think of anyway that I specifically prep for this?

And thank you! Btw, I find most of your posts to be really useful.

Brush up on your focused history and physical exam skills.

Familiarize yourself with diagnosis, monitoring, and treatment of HTN (familiarize yourself with JNC classification), diabetes, and hypercholesterolemia. These will be very high yield for your family medicine rotation. You'll look like a stud when a patient comes for DM management and you can spout off the appropriate labs they need, referrals (podiatry/ophtho), and suggestions for augmenting their treatment regimen.

 

[mimelim]

Brush up on your focused history and physical exam skills.

Familiarize yourself with diagnosis, monitoring, and treatment of HTN (familiarize yourself with JNC classification), diabetes, and hypercholesterolemia. These will be very high yield for your family medicine rotation. You'll look like a stud when a patient comes for DM management and you can spout off the appropriate labs they need, referrals (podiatry/ophtho), and suggestions for augmenting their treatment regimen.

I agree.

Similar to the inpatient model, learn the 10 most common diagnoses and how to work them up/treat. Understand the basic algorithm of HTN, DM2, HLD, CAD, OSA, MSK injury, etc.

By the end of your rotation, after you see a patient, you should try to come out of the room and end your brief presentation with, "And so I'd like to do XYZ to help better control/manage his ABC." or whatever analogous plan you can think of. Before starting, brush up on JNC7, ATP III, strep throat guidelines etc. You will look good, but more than that, you will learn a lot more if you have the basics down and can instead focus on honing your skills.

 

[VisionaryTics]

I agree.

Similar to the inpatient model, learn the 10 most common diagnoses and how to work them up/treat. Understand the basic algorithm of HTN, DM2, HLD, CAD, OSA, MSK injury, etc.

By the end of your rotation, after you see a patient, you should try to come out of the room and end your brief presentation with, "And so I'd like to do XYZ to help better control/manage his ABC." or whatever analogous plan you can think of. Before starting, brush up on JNC7, ATP III, strep throat guidelines etc. You will look good, but more than that, you will learn a lot more if you have the basics down and can instead focus on honing your skills.

Try doing it as soon as possible. Best way to learn (and get good grades).

 

[PTPoeny]

Presentation skills.

If you can give an organized patient presentation on rounds (or in clinic) early on in 3rd year you will be ahead of the curve. If you aren't comfortable speaking in small groups, work on that first. Then work on being comfortable with the organization of a patient presentation. Unfortunately it really doesn't matter how much you know if you cannot communicate that information on rounds.

 

[DermViser]

They shouldn't be doing them alone. But, it isn't much of a stretch to say that they should be able to do it alone/without guidance. I had 15 subclavians before I left medical school and more than 6 femorals and IJs. The first day of residency, if someone asked me to throw in a line, I would not have hesitated.

I don't know which med school you went to, but it must be a top 10.

 

[FutureInternist]

Since you only have a limited time to study, you have to try to figure out what to study

So if you have a CHF pt on your list, then you can bet your attending will ask the NYHA classes, when to use ACE, aldactone, & indications for a pacer

 

[NickNaylor]

Presentation skills.

If you can give an organized patient presentation on rounds (or in clinic) early on in 3rd year you will be ahead of the curve. If you aren't comfortable speaking in small groups, work on that first. Then work on being comfortable with the organization of a patient presentation. Unfortunately it really doesn't matter how much you know if you cannot communicate that information on rounds.

This really is key. I think residents and especially attendings will have more confidence in you if you can manage to get through a presentation without totally falling over yourself. I'd always pay very close attention on rounds the first day or two of a new block and get a sense for what kinds of things the residents talk about and leave out and emulate that.

Obviously pimping, not being a tool, etc. are also important, but giving a good presentation is both useful (since it keeps everyone up to date) and helpful for evaluation purposes. If you can give presentations equivalent to that of the intern, you are winning.


Sent from my iPhone using Tapatalk

 

[KinasePro]

This really is key. I think residents and especially attendings will have more confidence in you if you can manage to get through a presentation without totally falling over yourself. I'd always pay very close attention on rounds the first day or two of a new block and get a sense for what kinds of things the residents talk about and leave out and emulate that.

This is great advice, but I just want to caution a bit about the bolded text.

Some attendings/residents actually expect you to be painfully detailed and long-winded in your presentations simply by virtue of you being a medical student-- you've heard people say "the med student knows the patient the ebst, thier notes are the most helpful and complete, yada yada." So if you try to shorten it to the pertinent, resident-style presentation early in your rotation you might catch come flack. In my experience, this only happened on Medicine/Primary care, every other service wants you to STFU so the real doctors can finish rounds and move on w/ their lives (semi-srs)

So I'd recommend titrating your presentations-- start with the long-winded 7 minute medical student presentation, and then start trimming your presentations according to your team's expectations/ attention span.

 

[Priapism4tooLong]

Don't pretend to know something you don't know, be truthful and honest.

 

[mimelim]

I don't know which med school you went to, but it must be a top 10.

This has nothing to do with the 'ranking' of the school. If you have a county hospital, VA or are at a trauma center this is always going to be true.

 

[KinasePro]

This has nothing to do with the 'ranking' of the school. If you have a county hospital, VA or are at a trauma center this is always going to be true.

You're medical school experience seems to have been extremely hands-on by today's standards, though. There are a few tiers of trainees above students at the majority of medical schools in the US that prevent them from having the experience that you've described in a couple of these threads. May not have been ranked high or whatever, but your clinical training was way outside of the norm.

My school and (many of my friends', too) have VA and county hospitals, but still the GME machine prevents the students from getting anything but scraps at most places.