How to not look like an incompetent fool on rotations?

[NickNaylor]

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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.

Agreed - you make a good point. Early on I would have attendings correct me and essentially say exactly what you did - that even though the information was extraneous and unnecessary, they wanted me to report it just to ensure that I "was thinking about these things" and "being thorough."

That seemed to be less common as the year went on, though, but then again I started on medicine so that may have just been a function of the rotation.


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[DermViser]

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.

EXACTLY. Thank you. 👍👍👍

 

[DermViser]

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.

For some reason, Internal Medicine tends to highly revolve around making a big production on rounds. I wish I could understand why.

 

[DermViser]

Agreed - you make a good point. Early on I would have attendings correct me and essentially say exactly what you did - that even though the information was extraneous and unnecessary, they wanted me to report it just to ensure that I "was thinking about these things" and "being thorough."

That seemed to be less common as the year went on, though, but then again I started on medicine so that may have just been a function of the rotation.
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I thought it always sucked bc your attending would make you go thru all that, meanwhile the intern/resident are rolling their eyes bc they want to speed **** up faster. Funny how as a med student, rounds are going too fast and as an intern, rounds aren't going fast enough.

 

[mimelim]

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[KinasePro]

I have no way of knowing how much this has changed in the last 4 years or how much variation there is at various institutions across the country. My argument would be that it depends more on the student than it does on the institution in most cases (certainly not all). I say this because students at my home institution complained about not getting hands on experience and not being able to do anything. They were also the first people to disappear in the afternoon and among the least helpful at getting stuff done on rounds. Counting institutions... medical school x3 locations, 2 aways, 3 different hospitals/systems in Houston, thats 8 institutions total. Either as a student myself, or my students (now that I'm a resident), the students are getting to do basic procedures and being a part of the team. When I am on trauma and the students have their shelf or are otherwise off, I'm pissed. They help a lot. They grease the machine and can make a resident's life a lot easier. At the same time, I'm pretty annoyed with myself if my MS4 after a month isn't comfortable enough to do a central line by themselves, that is my failure, not theirs.

There are not enough procedures or hands on experiences for every single medical student to do all of this. But, to say that it doesn't exist at a lot of institutions is just not correct. I know, I read every applicant that we interviewed's file. I met the majority of them. I've seen my co-resident and our interns. They all showed up day one of residency with a similar background. The same? Of course not. But, as far as being able to function as a semi-useful intern on day one, absolutely.

I kinda figured that insinuation was coming. Maybe my med school is just full of Lake Wobegon students, but I don't know a single person who acts like the bolded quote. Quite the opposite, the vast majority are helpful, eager, and attentive at baseline and would do anything for the chance to put in lines and gain in the experience you're describing. Never saw a student "disappear" once during 3rd year, and everyone is pretty locked-in on rounds.

You have seen the training scheme at 8 hospitals, but realistically thats only 4 training institutions in your count. It's not the hospital that's the issue IMO, it's the medical training institution and their (sometimes) massive GME programs. Sure, county hospitals and VAs are great, but when there are copious interns/residents trying to make up for the skills no one taught them in medical school, the odds of a procedure making it down to the lowly med student are pretty slim. When it's not the interns/residents taking the procedures, sometimes its the NPs/PAs that were hired to pick up slack in the new era w/ work hour limitations.

(Oddly enough, no interns/residents/NPs rush to place foleys for some reason.. we'll always have that last refuge lol)

But you could be right, and maybe it's just the people in these threads who are the exception but I highly doubt it. I bet if we conducted a poll on SDN, very few people would align themselves with your training. At the residency programs at my institution, which are generally praised/highly competitive, we have residents from medical schools all over the country. They often cite their lack of hands-on experiences as med students for being the reason that they need do XYZ procedure instead of letting the med students try. I can't count how many times interns/residents have apologized to me for this, and I don't hold it against them at all bc I'll be doing the same thing in my intern year. It's a vicious cycle.

 

[Winged Scapula]

I would speculate that mimelin's experience would have been outside the norm even 10 years ago.

I only recall one of our interns being anywhere near facile with central lines and chest tubes; he thought it was because he was going to medical school at a notorious knife and gun club.

 

[DermViser]

I would speculate that mimelin's experience would have been outside the norm even 10 years ago.

I only recall one of our interns being anywhere near facile with central lines and chest tubes; he thought it was because he was going to medical school at a notorious knife and gun club.

I just figured it was a typical Vascular Surgeon setting very high expectations for his medical students (this is a compliment, not a putdown). Mimelin drinks, eats, and breathes medicine.

 

[mvenus929]

(Oddly enough, no interns/residents/NPs rush to place foleys for some reason.. we'll always have that last refuge lol).

There was a policy during my third year at my school that students were not allowed to place foleys, because the patients were experiencing higher rates of infections when students put them in.

Consequently, the only real procedures I did was closing the skin at the end of a surgical case. I barely got to suture in the ED, and just got really unlucky on my Trauma and OB months--we had a grand total of 3 deliveries while I was on on OB, and one I missed by like a minute because it was a precipitous delivery and I was occupied doing a note or something. The other two were given to the intern, who had to get a certain number of deliveries for the rotation. On my trauma rotation, we only had a handful of patients come in, and so the intern or second year residents got first crack at the procedures. I did get to intubate a couple times on Anesthesia, because it was toward the end of the academic year and the residents didn't care about it anymore.

So yeah, I know the theory for a lot of things, but I've never actually done most of them.

 

[Raryn]

I would speculate that mimelin's experience would have been outside the norm even 10 years ago.

I only recall one of our interns being anywhere near facile with central lines and chest tubes; he thought it was because he was going to medical school at a notorious knife and gun club.

I just finished my intern year and have completed a total of 10 central lines. Much less doing 15 as a medical student.

 

[operaman]

Just finished m3 and got to do quite a bit though not quite as much as some apparently. I think I could have done more if I'd been even more proactive and asked more than I did. I did this at times when I felt really comfortable with the team and was sure I wasn't being annoying, and invariably these were the times I got to do cool stuff. Maybe if I'd pushed a little more on others I could have done more procedure-wise. Even so, I feel like I'm in a good place for a new m4 and will hopefully do a lot more this year.

 

[mimelim]

I kinda figured that insinuation was coming. Maybe my med school is just full of Lake Wobegon students, but I don't know a single person who acts like the bolded quote. Quite the opposite, the vast majority are helpful, eager, and attentive at baseline and would do anything for the chance to put in lines and gain in the experience you're describing. Never saw a student "disappear" once during 3rd year, and everyone is pretty locked-in on rounds.

You have seen the training scheme at 8 hospitals, but realistically thats only 4 training institutions in your count. It's not the hospital that's the issue IMO, it's the medical training institution and their (sometimes) massive GME programs. Sure, county hospitals and VAs are great, but when there are copious interns/residents trying to make up for the skills no one taught them in medical school, the odds of a procedure making it down to the lowly med student are pretty slim. When it's not the interns/residents taking the procedures, sometimes its the NPs/PAs that were hired to pick up slack in the new era w/ work hour limitations.

(Oddly enough, no interns/residents/NPs rush to place foleys for some reason.. we'll always have that last refuge lol)

But you could be right, and maybe it's just the people in these threads who are the exception but I highly doubt it. I bet if we conducted a poll on SDN, very few people would align themselves with your training. At the residency programs at my institution, which are generally praised/highly competitive, we have residents from medical schools all over the country. They often cite their lack of hands-on experiences as med students for being the reason that they need do XYZ procedure instead of letting the med students try. I can't count how many times interns/residents have apologized to me for this, and I don't hold it against them at all bc I'll be doing the same thing in my intern year. It's a vicious cycle.

My point is that the opportunity exists at many schools/programs. And absolutely the average medical student isn't going to seek out those opportunities and isn't going to have any real numbers. And to be honest, this is a good thing because there aren't enough small procedures to go around. See my other comments later about resident's lack of experience (non-surgical).

I would speculate that mimelin's experience would have been outside the norm even 10 years ago.

I only recall one of our interns being anywhere near facile with central lines and chest tubes; he thought it was because he was going to medical school at a notorious knife and gun club.

I think that it is outside the norm. I don't think I've indicated otherwise. My point is that if you are looking for it, there are going to be opportunities to get hands on experience. When I rotated on Vascular as an MS4, there was an ortho intern and two fellows who essentially treated me as an intern. Yes, there were 2 MS3s, but neither were interested in surgery and barely showed up, much less stayed late to do cases. When I was at a conference a visiting fellow mentioned that he was pissed that his two interns got pulled for two months from then, so it would be 3 fellows and a PGY3 on service. I setup an away to coincide with that month. There are gaps in coverage all over the place. If you seek them out as a student, in general you will be rewarded. If you show up to your assigned rotations and expect to be walked through things, you aren't.

I just finished my intern year and have completed a total of 10 central lines. Much less doing 15 as a medical student.

I assume from your title that you are in IM. I'm not sure why this is surprising. Our IM residents don't do any lines. One our interns did 100+ that he recorded. He actually got in trouble because if you are doing that many lines, you are obviously losing out on other aspects of your education. At least when it comes to vascular access it is hard to compare IM to surgery, much less vascular...

 

[VisionaryTics]

My point is that the opportunity exists at many schools/programs. And absolutely the average medical student isn't going to seek out those opportunities and isn't going to have any real numbers. And to be honest, this is a good thing because there aren't enough small procedures to go around. See my other comments later about resident's lack of experience (non-surgical).

👍

I've said this before on other threads, I have done the exact same rotation contemporaneously with other students where I have done a ton of procedures and they have done none. The difference? I asked. The worst they could say is no.

On my EM rotation, on the first day, a guy came in septic and the resident decided to put a line in. I immediately asked if I could have a shot at it. I put the line in, and the residents remembered that. For the rest of the rotation, I got snagged to do procedures. In 2 weeks, I put in 6-8 central lines, put in an IO, debrided wounds, sutured lacs, drained abscesses, drained a septal hematoma, and put in a chest tube (highlight of M4 year). No one who did that rotation did close to what I did, and it was probably because I asked, made it known that I wanted to do procedures, and always grabbed supplies and knew the steps beforehand.

Also, procedures beget procedures. I drained the septal hematoma because a random attending was watching me put the chest tube in from the doorway and started talking to me about it afterwards. He asked what I was going in to, and when I said ENT, he pulled me in to do the procedure. I don't think that would've happened if I were standing in the corner while my resident put in the tube or if I was in the team room or if I was at home.

Yeah, there are plenty of rotations where I did jack squat despite asking a lot (for example, my ENT subI where I sutured one thyroid incision closed in 4 weeks), but if you do the right rotations, at the right locations, with the right residents, you can get some hands on experience as a med student. It sounds like @mimelim has those experiences.

And it has nothing to do with "tier" of medical schools. I got most of my hands-on experiences at places @DermViser decried as "IMGs mills".

 

[alpinism]

👍

I've said this before on other threads, I have done the exact same rotation contemporaneously with other students where I have done a ton of procedures and they have done none. The difference? I asked. The worst they could say is no.

On my EM rotation, on the first day, a guy came in septic and the resident decided to put a line in. I immediately asked if I could have a shot at it. I put the line in, and the residents remembered that. For the rest of the rotation, I got snagged to do procedures. In 2 weeks, I put in 6-8 central lines, put in an IO, debrided wounds, sutured lacs, drained abscesses, drained a septal hematoma, and put in a chest tube (highlight of M4 year). No one who did that rotation did close to what I did, and it was probably because I asked, made it known that I wanted to do procedures, and always grabbed supplies and knew the steps beforehand.

Also, procedures beget procedures. I drained the septal hematoma because a random attending was watching me put the chest tube in from the doorway and started talking to me about it afterwards. He asked what I was going in to, and when I said ENT, he pulled me in to do the procedure. I don't think that would've happened if I were standing in the corner while my resident put in the tube or if I was in the team room or if I was at home.

Yeah, there are plenty of rotations where I did jack squat despite asking a lot (for example, my ENT subI where I sutured one thyroid incision closed in 4 weeks), but if you do the right rotations, at the right locations, with the right residents, you can get some hands on experience as a med student. It sounds like @mimelim has those experiences.

And it has nothing to do with "tier" of medical schools. I got most of my hands-on experiences at places @DermViser decried as "IMGs mills".

Completely agree and I've also had the same experience.

Its not just about showing up, being available, and having a good attitude on rotations. Unfortunately, the baseline for most residents and attendings is to just have you observe and mainly practice doing H&Ps, writing notes, and presenting patients. Anything beyond that is an afterthought. If you want hands on experience, you have to be extremely proactive. That's the bottom line. And by that I mean you have to look for opportunities everyday and constantly ask if you can have a shot at the next that procedure needs to be done.

Not surprisingly, I did most of my procedures on surgery at 2am when I volunteered to stay the night for trauma call.

 

[KinasePro]

My point is that the opportunity exists at many schools/programs. And absolutely the average medical student isn't going to seek out those opportunities and isn't going to have any real numbers. [...] There are gaps in coverage all over the place. If you seek them out as a student, in general you will be rewarded. If you show up to your assigned rotations and expect to be walked through things, you aren't..

I'm in 100% agreement with your philosophy. You need to be a go getter as an M3, show interest and be competent, etc... But as the responses in these threads illustrate, many people do these things and but there simply aren't the same opportunities you describe at many medical schools.

I mostly take issue with the bolded statement, which implies that people who aren't getting the same clinical experience are twiddling their thumbs. There are plenty gung ho medical students at my school, myself included, but for every chest tube that needs placed there are 5 fellows/residents/interns/NPs who find out about it before the student does.

On my surgery rotations and trauma calls, med students are frequently caught up in scut which they unfortunately can't abandon in exchange for a procedure which can be done in half the time by someone who is 10x as competent as the student. You can imagine how you're eval would suffer if you're constantly skipping out on tasks given to you by your team in order to gain procedural experiences that are normally designated to those higher up in the hierarchy.

I've said this before on other threads, I have done the exact same rotation contemporaneously with other students where I have done a ton of procedures and they have done none. The difference? I asked. The worst they could say is no.

And it has nothing to do with "tier" of medical schools. I got most of my hands-on experiences at places @DermViser decried as "IMGs mills".

I'd actually argue that being at an "IMG mill" is probably beneficial to your clinical training as a medical student, because it implies that the residencies aren't as "strong" and there is more work left for other trainees.

I can count the IMG residents I've met at my institution on one hand. It's a high volume urban center known for "strong" surgical residencies, but unfortunately (for us students) the residents get priority in hands-on training in this setting.

Don't get me wrong, I'm not complaining about my experience at my school. I've had some great experiences in the OR and have been 1st assist and even been allowed to open and dissect in simple cases. I've probably closed more than 30 surgical cases as well, thanks to showing initiative and interest. But I only take issue with the implication that if you're not doing lines/chest tubes as a student, you're just not trying hard enough. In my experience, by the time I find out about the chest tube/line, it's already being taken care of by a resident or NP.

 

[drcrispmd]

You have gotten some good advice so far. Here is some more

1. Do Not Be Late.
2. Do not complain about how tired you are. Most of the time residents are putting in many more hours than you and do not want to hear how tired you are.
3. iron your clothes
4. shower
5. wash your white coat regularly
6. do not throw fellow students under the bus and definitely do not throw your residents under the bus
7. things said in the call room stay in the call room. do not go telling attendings what so and so resident said in the call room
8. do not disappear or leave early
9. On surgery: if your resident is tied up with a case and the cafeteria closes early, get them something for lunch. Also applies to OB. The cafeteria at the hospital I did my rotations at 3rd year closed at 2pm. Sometime impossible to get there before it closed. This is just a curtosey thing and residents will appreciate it.
10. realize that lunch may not be at noon every day. do not tell a resident you can't do something becaue you need to get lunch. keep something in your locker or a protein bar in your pocket (this is good advice for surgery).
11. never skip breakfast on surgery or OB.
12. do not try to show up residents, especially in front of an attending. it does not look good for you
13 for surgery, we were told to keep tape and packs of 4x4 in our pockets at all times
14. if a resident tells you to go home, go home
15. act interested and eager to learn. if you act like you do not care, residents will not take the time to teach you
16. do not ask residents if there is anything you can do for them and then complain about scut work
17. do not wear a long white coat as a student
18. be nice to the nurses. this will be very helpful if you become a resident at that same hospital. nurses remember. they can help you as students or make things difficult.
19. learn to use please and thank you.
20. If you are on overnight call and your resident is awake and doing patient care, you should be awake too unless the resident has told you to go to bed.
21. turn your phone on vibrate.
22. things to keep in your locker/bag: tums, imodium, tylenol/motrin, gum, snacks, relevant books for rotation, extra set of clothes and socks, contact solution, deodarant, tooth brush and paste. You do not want to be attacked by horrible acid reflux in the middle of the night and no where to buy relief.

Good luck. you will get frustrated a lot. be irritable at times. wonder why you chose medicine sometimes. But you will learn a lot!

 

[KnuxNole]

I thought it always sucked bc your attending would make you go thru all that, meanwhile the intern/resident are rolling their eyes bc they want to speed **** up faster. Funny how as a med student, rounds are going too fast and as an intern, rounds aren't going fast enough.

That's how I feel too. I love rounds in residency compared to med school because in residency, they are about getting work done, getting patients discharged/taken care of, and done in 1 hour or less. In med school, especially, IM, rounds lasted 3-5 hours. Which SUCK. I don't care about long winded discussions, I want to do my job! Thankfully, in the residency world, that seems to be the case 🙂

 

[DermViser]

That's how I feel too. I love rounds in residency compared to med school because in residency, they are about getting work done, getting patients discharged/taken care of, and done in 1 hour or less. In med school, especially, IM, rounds lasted 3-5 hours. Which SUCK. I don't care about long winded discussions, I want to do my job! Thankfully, in the residency world, that seems to be the case 🙂

I think it also helps bc YOU are the one getting the pages, YOU are the one seeing patients and actively getting a history, doing a physical, coming up with an A&P, and writing orders (which then you have to rely on the nurse actually doing). It's so much easier to be in the loop, when you're actually in the loop.

 

[NickNaylor]

I think it also helps bc YOU are the one getting the pages, YOU are the one seeing patients and actively getting a history, doing a physical, coming up with an A&P, and writing orders (which then you have to rely on the nurse actually doing). It's so much easier to be in the loop, when you're actually in the loop.

I'm glad that both of you have had this experience. I was hoping that would be the case when I get into residency.

 

[DermViser]

I'm glad that both of you have had this experience. I was hoping that would be the case when I get into residency.

Don't get me wrong, I hated being paged by nurses for stupid ****, esp. if it was at a ridiculous hour (much more with floor nurses vs. ICU nurses who are awesome). But, I always felt as a medical student that I wasn't getting the full picture or story, bc there would be some integral part of the story missing that I would have no way of knowing --- resident got paged about something that changed the management that wasn't relayed to me, or got some piece of information from the family that I wouldn't know bc they had long gone by that time. It's even better when you have a great upper level who knows when to help you when you're drowning, and when to push you a little further and let you be independent to help you grow.

 

[NickNaylor]

Don't get me wrong, I hated being paged by nurses for stupid ****, esp. if it was at a ridiculous hour (much more with floor nurses vs. ICU nurses who are awesome). But, I always felt as a medical student that I wasn't getting the full picture or story, bc there would be some integral part of the story missing that I would have no way of knowing --- resident got paged about something that changed the management that wasn't relayed to me, or got some piece of information from the family that I wouldn't know bc they had long gone by that time. It's even better when you have a great upper level who knows when to help you when you're drowning, and when to push you a little further and let you be independent to help you grow.

Yeah, this was a huge source of frustration for me on the in-patient rotations. It also made it difficult to really understand treatment regimens and indications for various things when plans were being changed for seemingly no reason. I always appreciated when residents would keep the med students in the loop on their patients. Some of them felt like if the med students looked stupid it would reflect poorly on them. Incidentally enough, those were also the most enjoyable and educational rotations that I had.

 

[seminoma]

Sorry for the necrobump, but I think this thread has a bunch of excellent information. I bookmarked it back in MS1 so I could read it before starting MS3.

Anyway, I was wondering if anyone could comment on striking a balance between asking questions that demonstrate you've read about the patient and sounding like you're trying to make the resident and/or attending look stupid. For example, as part of our orientation for the start of the medicine clerkship we did a practice oral presentation today. Basically we were given a H&P and labs and then we showed up and presented to an attending. The patient I was assigned had (unrelated to the chief complaint) incidental findings of a skin papilloma and a thyroid nodule and I started thinking about cowden syndrome. Chief complaint was actually fatigue and there was a microcytic anemia possibly related to a GI bleed. Anyway, I presented the case and as I was about to go into my A&P the attending cut me off, gave some feedback about my presentation and then asked my group of classmates for their feedback. The attending then gave their A&P and before we moved on to the next student presentation I asked if genetic screening for PTEN is a reasonable thing to do. The attending looked at me as if I was speaking in a foreign language and said "what?". I repeated myself.. asking about PTEN and saying I was considering cowden syndrome in my differential. The attending then shook his head and said he didn't know what PTEN was and then called on the next person to present. The look on his face was also not one of "cowden syndrome is a good thought, but I'm not familiar with PTEN". It was more like "why are you wasting my time with this crap?"


I'm usually pretty good about not going straight to the zebra differential, but this one didn't seem like it was unreasonable.. and I definitely didn't consider the fact that the attending might not be familiar with cowden or PTEN. So I guess.. advice?

 

[VisionaryTics]

Sorry for the necrobump, but I think this thread has a bunch of excellent information. I bookmarked it back in MS1 so I could read it before starting MS3.

Anyway, I was wondering if anyone could comment on striking a balance between asking questions that demonstrate you've read about the patient and sounding like you're trying to make the resident and/or attending look stupid. For example, as part of our orientation for the start of the medicine clerkship we did a practice oral presentation today. Basically we were given a H&P and labs and then we showed up and presented to an attending. The patient I was assigned had (unrelated to the chief complaint) incidental findings of a skin papilloma and a thyroid nodule and I started thinking about cowden syndrome. Chief complaint was actually fatigue and there was a microcytic anemia possibly related to a GI bleed. Anyway, I presented the case and as I was about to go into my A&P the attending cut me off, gave some feedback about my presentation and then asked my group of classmates for their feedback. The attending then gave their A&P and before we moved on to the next student presentation I asked if genetic screening for PTEN is a reasonable thing to do. The attending looked at me as if I was speaking in a foreign language and said "what?". I repeated myself.. asking about PTEN and saying I was considering cowden syndrome in my differential. The attending then shook his head and said he didn't know what PTEN was and then called on the next person to present. The look on his face was also not one of "cowden syndrome is a good thought, but I'm not familiar with PTEN". It was more like "why are you wasting my time with this crap?"


I'm usually pretty good about not going straight to the zebra differential, but this one didn't seem like it was unreasonable.. and I definitely didn't consider the fact that the attending might not be familiar with cowden or PTEN. So I guess.. advice?

1. This is unreasonable jump to Cowden. Anemia, thyroid nodules, and papillomas are all incredibly, incredibly common diagnoses. You will shine as a med student if you have a good plan for working up anemia, recommending FNA and TSH/T4 for thyroid nodule, and noting papillomas on your physical exam.

2. Your job is to become facile with the basics of patient care: good H&Ps, reasonable A&Ps. Do NOT "ask questions that demonstrate you've read about the patient". It's a self-serving waste of time and could piss off your co-students, residents, and attendings. However, you SHOULD demonstrate that you've read about the patient through your A&P, which should be reasonable and thorough. Bringing up something like Cowden syndrome during rounds is a waste of time because the patient has multiple undifferentiated issues (fatigue, anemia, nodule) that need to be worked up first.

Don't be that med student who pulls obscure diagnoses and journal articles out of their ass to sound smart (which is probably what you really mean when you say "demonstrate you've read about the patient"). You have enough to learn about just the basics of patient care.

 

[seminoma]

1. This is unreasonable jump to Cowden. Anemia, thyroid nodules, and papillomas are all incredibly, incredibly common diagnoses. You will shine as a med student if you have a good plan for working up anemia, recommending FNA and TSH/T4 for thyroid nodule, and noting papillomas on your physical exam.

2. Your job is to become facile with the basics of patient care: good H&Ps, reasonable A&Ps. Do NOT "ask questions that demonstrate you've read about the patient". It's a self-serving waste of time and could piss off your co-students, residents, and attendings. However, you SHOULD demonstrate that you've read about the patient through your A&P, which should be reasonable and thorough. Bringing up something like Cowden syndrome during rounds is a waste of time because the patient has multiple undifferentiated issues (fatigue, anemia, nodule) that need to be worked up first.

Don't be that med student who pulls obscure diagnoses and journal articles out of their ass to sound smart (which is probably what you really mean when you say "demonstrate you've read about the patient"). You have enough to learn about just the basics of patient care.

Thanks for the input. I guess I'm stuck in the thought process of "everyone will know the basics so how do I set myself apart?" and I realize now that obscure diagnosis isn't the right path to that. Also one of the things our MS2 lecturers focused on was "make one diagnosis" and in my mind cowden is a diagnosis that encapsulates fatigue/anemia (gi neoplasm), thyroid nodule, and papilloma. I recognize that MS2 lectures aren't the real world and that real people have multiple problems, but it's a habit I have yet to break.

I guess the question I should've asked is what do you recommend MS3s do to show that they're trying to do more than the minimum? My understanding is that all the things you listed are the minimum expectations of an MS3, but I am probably completely wrong.

Edit: Also I realize that the "minimum" is probably more than enough work as it is and I may struggle to even accomplish that much, but I would just like to know how to show that I'm actually trying and not just trying to get by. I mean, isn't perception the majority of the non-shelf component of your clerkship grades?

 

[Psai]

you don't know the basics
that's what third year teaches you

 

[link2swim06]

Just realize the following....
1. At this point EVERYONE in the hospital knows more than you...the nurse, the pharmacist, the M4s, the residents, the attending...hell probably the clerk/secretary. This is day 1 of ~1000-3000 in your clinical training. You have time to figure stuff out but need to study hard. But just remember everyone else has been doing this for a lot longer.
2. Most of what you need to know to be a doctor you have not learned yet.
3. M3 is about: learning to take histories, developing workup plans, and diagnoses/treatments.

Bottom line...don't stress out too much. In a few thousand days you will be done and an expert in something.

Enjoy the ride.

 

[Vexare]

Thanks for the input. I guess I'm stuck in the thought process of "everyone will know the basics so how do I set myself apart?" and I realize now that obscure diagnosis isn't the right path to that. Also one of the things our MS2 lecturers focused on was "make one diagnosis" and in my mind cowden is a diagnosis that encapsulates fatigue/anemia (gi neoplasm), thyroid nodule, and papilloma. I recognize that MS2 lectures aren't the real world and that real people have multiple problems, but it's a habit I have yet to break.

I guess the question I should've asked is what do you recommend MS3s do to show that they're trying to do more than the minimum? My understanding is that all the things you listed are the minimum expectations of an MS3, but I am probably completely wrong.

Edit: Also I realize that the "minimum" is probably more than enough work as it is and I may struggle to even accomplish that much, but I would just like to know how to show that I'm actually trying and not just trying to get by. I mean, isn't perception the majority of the non-shelf component of your clerkship grades?

Caveat: Just finished MS3 myself so not an expert but I can tell you what I've learned throughout my year.

You would think it would be the minimum for most MS3s but in my experience, so many students get flustered or deliver poorly organized presentations that their knowledge of the work-up gets lost in a lot of unnecessary info, that is, if they had a thorough knowledge of the work-up to begin with (which, don't worry, you'll be working on all year so it'll come with time).

In response to your question about how to set yourself apart, there's good advice all over this thread but here's what worked for me:
1. Get your presentations down to an art (be succinct but thorough, read the room so you're not going on and on when the rest of the team just wants to move on, make a note of little tidbits that may have been mentioned before but never addressed and follow-up on them, make your residents aware, and if they're cool with it, be the one to present it if its relevant)
2. Have a broad, relevant knowledge base (a lot of times MS3s get wrapped up in the rotation they're in and forget that a lot of medicine shows up again on surgery, peds can find its way into OB-GYN or family med, and psych can show up anywhere; remembering basic but key management points I've learned in other rotations and then being able to suggest or apply them to future rotations seems simple enough, but you'll be surprised how helpful it is)
3. Be a cool person. Seriously. (MS3 is about learning a lot and figuring out what specialty you want to do and the rest, but for several weeks at a time you are also a part of the medical team and no one wants to work with a gunner, a lazy student or someone without a personality. Feel free to let yourself go sometimes [within reason] and you may be surprised at how your residents respond. If they enjoy being around you this whole experience doesn't have to be so brutal and they'll be far more willing to teach you things, let you do procedures, back you up in front of attendings and generally make your life much easier. In return, do the same for them. That's what being a part of the team means. Don't disappear, don't put others down, don't shirk responsibility. All of this seems like common sense but if you're not aware of how you come off to other people you may be doing it without realizing).

Anyway, I'm sure I could go on but I think you get the idea. What worked for me was just putting my best foot forward and being a good team member before trying to be the brilliant med student. You'd be surprised - do what myself and others have recommended and you will stand out, guaranteed. Don't need Cowden syndrome to do that (though coming off of Step1, I see why you would think that right away, it's just a different mindset after MS2).

 

[Kahreek]

...

 

[cbrons]

Thanks for the input. I guess I'm stuck in the thought process of "everyone will know the basics so how do I set myself apart?"

Lol if you are 3rd year who "knows all the basics" you are a damn good student (and 99% of m3s do not)

 

[Psai]

Lol if you are 3rd year who "knows all the basics" you are a damn good student (and 99% of m3s do not)

i still don't know the basics

 

[hopefulERdoc251]

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.

This NEEDS to be stickied.