How to teach new clerkship students

[thecerebellum]

Hey all,

I’m an intern at a big program, and struggling with wanting to be a good teacher to medical students while also being super busy in the mornings before rounds. At my program, interns take responsibility for clerkship students (while seniors do so for subIs). We have brand new clerkship students starting in Jan, and I was hoping some third years or residents could chime in for the most helpful things interns taught them or things they wished were done to help them learn. I’ve been told “just include them in everything you do” but that seems super vague and it isn’t feasible for me to narrate my work flow in prerounding on, writing notes for, and making treatment plans for up to 10 patients before 8 am. I recognize I’m not so far from a third year so maybe I ought to remember but my med school wasn’t as big of a program so interns/residents weren’t very busy.

Thanks!

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[AlbinoHawk DO]

What specialty will you be helping the students with?

 

[thecerebellum]

Well, it would be nice to not be "note b**ch" for a change. Or, if residents didn't use students to constantly look up things for them because they're lazy. Or, actually being asked specific questions not in the vein of "so, what do you think?" These 3 things are pretty much how every resident I've ever encountered functions and it makes me long for only have an attending to work with as they actually teach and show you how to be a doctor.

Just my .02

My usual move with students is give them as much autonomy as possible in managing their 1-2 patients, but that’s been with the end of clerkship students, not new ones so that’s why I asked. I’m sorry your experience was that way, but in my program students write notes just for themselves (we write our own), and if they’re looking something up it’s because an attending asked not because residents ask them to. Usually I have more trouble getting students to engage and become involved with the team in a way that’s useful to both them and to the team, so that’s what I’m hoping to hear ways to improve on. The field is Peds.

 

[Lawpy]

This thread looks promising, and I think @Oso @BigRedBeta @SurfingDoctor @mvenus929 could provide some useful tips.

I'm more focused on making the grading less subjective/more standardized with clear guidelines for students on what to expect.

 

[SurfingDoctor]

They should be examining patients, talking to families and writing notes on day one, not the end of the rotation. You learn by doing, not watching but that’s my opinion.

As for explicit teaching while rounding (or prerounding), tell them what is important, why and what you think the next steps should be. By the end of the month, you ask them what they think is important, why and what the next steps should be. If there is a clinical pearl, “this antibiotic is useful for this type of infection because...” mention it at the time.

 

[bananafish94]

Thank you for taking the time to make a thread like this! Speaking only for myself, I love when I get an opportunity to learn and practice universally useful, "high yield" things for clinical practice. For example, interpreting ECGs, x-rays, etc. and going through bread-and-butter illnesses relevant to the specialty beyond textbook/shelf knowledge. I also think that being very open about your expectations and how you grade is unbelievably useful to medical students - everyone has at least one story about how they got blindsided by an evaluation of straight 2/4 or 3/5 despite getting great verbal feedback.

 

[thecerebellum]

They should be examining patients, talking to families and writing notes on day one, not the end of the rotation. You learn by doing, not watching but that’s my opinion.

As for explicit teaching while rounding (or prerounding), tell them what is important, why and what you think the next steps should be. By the end of the month, you ask them what they think is important, why and what the next steps should be. If there is a clinical pearl, “this antibiotic is useful for this type of infection because...” mention it at the time.

Everything you wrote sounds like great teaching, thanks! Do you think your techniques vary when it’s a clerkship student on their very first rotation rather than an end of clerkship year student? That’s what I meant by new clerkship students... I’m just not sure they’d all feel comfortable seeing patients and families by themselves right away. Though even for new clerkship students I’d expect plenty of growth by the end of the month on our team.

 

[SurfingDoctor]

Everything you wrote sounds like great teaching, thanks! Do you think your techniques vary when it’s a clerkship student on their very first rotation rather than an end of clerkship year student? That’s what I meant by new clerkship students... I’m just not sure they’d all feel comfortable seeing patients and families by themselves right away. Though even for new clerkship students I’d expect plenty of growth by the end of the month on our team.

Gotta get their feet wet sometime. They should be able to introduce themselves, ask about family or patient concerns, get info from the nurses and provide a cursory exam. Maybe not day one, because they need to learn the system and work flow, but by the end of the first week.... yes.

 

[mvenus929]

Few questions:

1. Brand new as in starting 3rd year, or as in starting a new rotation?
2. What is the structure of the inpatient team at your institution? That will make a huge difference in their experience.

In my residency, we had 2-4 interns per team that divided the workload evenly. The seniors usually managed the admits in the morning, and then distributed them to the interns in the afternoon after rounds. Med students were also primarily responsible for admissions and for carrying 1-3 patients day to day (depending on acuity, census, and experience/trust level). So the senior would do the bulk of the teaching with the new admits and the interns were more responsible for the teaching on the patients day to day (including preparing their student to present on rounds). It became more challenging to teach them in my third year because the structure of the clerkship changed so that the students left by 3pm each day, and only stayed on a service for 2 weeks, during which they likely missed several days due to rotating on nights, so there rally wasn’t time to build rapport and trust with the students.

In general, my suggestions are as follows:
1. Try to have one med student paired with one intern. It gets chaotic when they try to run plans by you in the morning if they’re trying to find 3 different interns.
2. Have them present to you after they preround. Throughout the rotation, they should go from reporting information to you, to synthesizing all the information into a diagnosis, to coming up with broad management plans (they should not be expected to know drug doses, but it’s reasonable for them to attempt to choose an antibiotic that would be useful in the clinical scenario). Challenge them to do so, but emphasize that it is a safe space—that’s why they are presenting to you before they present to the whole group. The goal is for them to do all the presenting and for you to chime in with “I agree” on rounds.
3. Offer teaching points in the minute. For example, you have a kid with bronchiolitis... discuss how the lung exam may be different in a kid with bacterial pneumonia. Or in a fever in a neonate, discuss how age may impact management.
4. Take them back with you when you reassess the patients in the afternoon and talk to the families. Even if they are just shadowing during that time, it’s useful to see.
5. If you’re doing an admission together, give them one task to focus on that you can offer feedback about after the encounter. For instance, if you’re admitting a kid with bronchiolitis, review the important questions to ask as part of the HPI and give them feedback on that at the end. Or have them focus on the exam while you gather the history.

There’s a teaching concept called minute preceptor or something along those lines. That offers good examples of how to give small teaching points in the context of patients without getting bogged down with giving an entire lecture. I’m still working on my teaching abilities, but doing that goes a long way.

 

[thecerebellum]

1. Brand new as in starting 3rd year, or as in starting a new rotation?
2. What is the structure of the inpatient team at your institution? That will make a huge difference in their experience.

I’m talking about brand new starting third year as that’s what’s coming up in Jan on my next block (at this med school it’s 18 month preclinical, then clerkship in Jan). My team structure is similar to yours. Seniors for the most part function to watch over the whole team, but are mostly not involved with individual patients or admissions unless something comes up, so that’s why it’s really the interns teaching third year students. I think a big problem has been that it’s hard for students to do admissions because they’re only really there til 3 most days (usually they want to leave to study which is fair) or have a few days to stay til 7-8 pm. Most admissions happen late pm or overnight and they don’t do nights.

I also really liked your suggestions above and will look into the teaching tool you mentioned. I’m just trying to figure out the best way to have the time in the mornings to hear their whole presentation and walk them through a management plan they’re supposed to be presenting when they’re just starting off and likely have no clue what our management is for bronchiolitics etc - hence why they need teaching that lasts longer than 15 minutes prior to rounds (or I need to get better at teaching more efficiently). The students I worked with this fall already knew how to present and needed to know if their assessment/plans (which I encouraged them to work on and then discuss with me) were similar to what I was thinking.

 

[operaman]

I have struggled with this for awhile. We only get clerkship students who pick our field as an elective and then we get a boatload of Sub I’s.

I find the clerkship kids rather challenging. Many are very timid and blend into the paint and take little interest in anything despite my reaching out to them. Our rounding style also doesn’t lend itself to the typical student seeing and presenting their patients. Our clerkship kids also have a LOT of mandatory lectures and whatnot that pull them out precisely at those times when I could actually teach something.

For those that are interested:

1) good old fashioned pimping
2) get them sewing in the OR or on call. Our big free flap recons often need a ton of sewing that can be done concurrently with other parts so students who want to can take their time practicing sewing.
3) basic physical exam stuff. Most students at the clerkship level struggle with their exam and benefit from some guidance.
4) advanced exam skills- I’ve let a number of students do flexible endoscopy on me, do exams under binocular microscopy, etc.
5) airway management - learning to bag mask effectively is one of the most important and least taught skills, so I try to let students do it whenever possible. I also do a lot of teaching on the concepts involved in airway management.
6) temporal bone work- I’ve taken a couple highly motivated students through drilling a mastoid and placing a cochlear implant. This is more for people strongly considering the field to help them learn the anatomy and also get a taste of otologic surgery.
7) chalk talks on bigger picture topics- nuances of anatomy, stridor/stertor, concepts of cancer staging, reading CT and MRI scans, etc.

 

[plasticsday1]

tbh the best thing you can do for an MS3 is send them home asap so they can study for the shelf

 

[mvenus929]

I’m talking about brand new starting third year as that’s what’s coming up in Jan on my next block (at this med school it’s 18 month preclinical, then clerkship in Jan). My team structure is similar to yours. Seniors for the most part function to watch over the whole team, but are mostly not involved with individual patients or admissions unless something comes up, so that’s why it’s really the interns teaching third year students. I think a big problem has been that it’s hard for students to do admissions because they’re only really there til 3 most days (usually they want to leave to study which is fair) or have a few days to stay til 7-8 pm. Most admissions happen late pm or overnight and they don’t do nights.

I also really liked your suggestions above and will look into the teaching tool you mentioned. I’m just trying to figure out the best way to have the time in the mornings to hear their whole presentation and walk them through a management plan they’re supposed to be presenting when they’re just starting off and likely have no clue what our management is for bronchiolitics etc - hence why they need teaching that lasts longer than 15 minutes prior to rounds (or I need to get better at teaching more efficiently). The students I worked with this fall already knew how to present and needed to know if their assessment/plans (which I encouraged them to work on and then discuss with me) were similar to what I was thinking.

Focus on one thing each day. Don’t try to fix the entire presentation on day 1. Start with summarizing a new patient’s history, or giving the subjective from overnight on a known patient. Then move on to the next thing. For the bread and butter stuff, find Peds in Review articles for them to read—it should help with the shelf and gives them something besides case files to read.

And most importantly, emphasize the differences between patients. Why one kid gets antibiotics and the other is observed. why one kid is discharged after overnight obs but one stays for 4 days. And if you don’t know yourself, bring it up on rounds so the whole team can learn.

If they are brand new, they are going to struggle with 1 or 2 patients. Spend those 15 minutes in the morning, but if there is more to go over, grab them after rounds to go over it. If the patient isn’t going to be discharged that afternoon, you can go over the presentation in the afternoon the day before too.

 

[CherryRedDracul]

Pre-morning rounds, I focused on getting my work done.

I have struggled with this for awhile. We only get clerkship students who pick our field as an elective and then we get a boatload of Sub I’s.

I find the clerkship kids rather challenging. Many are very timid and blend into the paint and take little interest in anything despite my reaching out to them. Our rounding style also doesn’t lend itself to the typical student seeing and presenting their patients. Our clerkship kids also have a LOT of mandatory lectures and whatnot that pull them out precisely at those times when I could actually teach something.

For those that are interested:

1) good old fashioned pimping
2) get them sewing in the OR or on call. Our big free flap recons often need a ton of sewing that can be done concurrently with other parts so students who want to can take their time practicing sewing.
3) basic physical exam stuff. Most students at the clerkship level struggle with their exam and benefit from some guidance.
4) advanced exam skills- I’ve let a number of students do flexible endoscopy on me, do exams under binocular microscopy, etc.
5) airway management - learning to bag mask effectively is one of the most important and least taught skills, so I try to let students do it whenever possible. I also do a lot of teaching on the concepts involved in airway management.
6) temporal bone work- I’ve taken a couple highly motivated students through drilling a mastoid and placing a cochlear implant. This is more for people strongly considering the field to help them learn the anatomy and also get a taste of otologic surgery.
7) chalk talks on bigger picture topics- nuances of anatomy, stridor/stertor, concepts of cancer staging, reading CT and MRI scans, etc.

Re: pimping, I learned the most when I was pimped because I forced to think through a question and come up with a reasonable answer, and if I was wrong, there was a strong emotional reaction to that. With that emotional reaction and whatever instruction I received subsequently, I had a tendency to remember and retain whatever facts I learned.

It's called emotional anchoring. I pimped medical students as an intern, not on trivia, but clinically relevant matters. I explored what they knew and what they had yet to learn and sought to fill in their blanks. If I had enough free time, I'd sit down with them we'd draw out diagrams, tables, pictures, whatever, to solidify their learning.

As a radiology resident, I still pimp the medical students. Hell, I wish I was pimped in the reading room as a medical student because otherwise I fell asleep. I'll introduce a topic, teach them, and several minutes later, show them a case and revisit what I taught them and pimp them.

 

[thecerebellum]

I was lucky to have some really amazing teaching from a few interns/residents in my third year. Here were things my favorites ones did:

- In the first couple days, sat down with me and told me what their expectations are. We have no clue where to stand, let alone where to be useful - just a little direction can really open up some opportunities to learn and minimize the amount of time we're taking out of your day.
- Also in the first couple days, had me come see a new admit and a continuing patient (pre-rounding) with them. Let me see their workflow and talked through everything they were doing (When I'm chart checking before I see a patient, I'm looking for X. For continuing patients you always want to make sure you include Y in your note. Here's how I like to put labs into my note. Here's the dot phrase I use.) You don't have to do this daily - just once or twice at the beginning of their time so they get a feel for how they can be helpful to you for the next couple bullets.
- Let me see consults/admits on my own - see the patient, write a full note, and take a stab at the assessment/plan. I would then present all this to the intern, who'd prep me to present to the senior/attending. If I was missing something, told me so and explained why it's important. This is obviously going to take a long time for a fresher M3, but for me it was SUCH a good learning experience.
- Once those patients were admitted/consulted on our service, those were "my" patients. I followed them to discharge. I pre-rounded on them every day, wrote those notes, and presented them on rounds. Took care of their paperwork to get records, updated patients and family when possible, etc.
- A couple times a week, had me pick one of my notes to go through together and get feedback.
- For the more procedural specialties, actually taught me some skills I could do on my own on the floor like changing dressings, taking out staples, removing drains, etc. These are super basic and take 5 minutes to learn, but they do make us feel useful lol, and save you a little time as well.

This is a lot of responsibility and they're going to spend a lot of time on the struggle bus, especially on their first few clerkships. And that's okay! That's what third year is about. Make sure you're providing a good balance of throwing them in the deep end but being there for support when they need it. My best residents pushed me to figure things out on my own - they made me look stuff up and tell them about it if I had a more basic level question - but never made me feel bad for asking questions or needing help when it was a reasonable thing for an M3 not to know.

THANK YOU for trying to be a good teacher!!

Awesome! This was super helpful. Just wondering - do you think you were an exceptionally interested/engaged MS3? The suggestions you make to have them do their own admissions etc are things I try to do, but it can be a challenge to get students to do this sometimes (I’ve had a few turn down doing admissions to leave to study or because the patient was “complex” and not a classic general pediatrics case)

 

[Oso]

Well, it would be nice to not be "note b**ch" for a change

lol you're not gonna like intern year.


In general, I like giving them a little bit more responsibility each day. Though it varies by the student. I've seen some (especially now that we're halfway through the year) who just want to hit the ground running and that's awesome.

I also like to make sure I teach them one useful thing each day. And to have them explain the plan to the patient/parents if possible, as it's good practice. I also feel that having them call a few consults is good practice, though I make sure I'm sitting next to them and available to help out if needed.

In terms of having students look things up. This is not because we are "too lazy". It's because, at least as an intern, I am hella busy and sometimes only have enough time to look into things that I need immediately to take care of the patient. For example, I had to take care of a patient with HLH recently and only knew a bit about it. The student offered to look into it more deeply and give a presentation at the end of the day, which was awesome, because I learned about the basic science/pathophysiology of it much more in depth than I would have otherwise that day. Teaching can go both ways.

 

[Lawpy]

- Give REAL feedback. #1 complaint my classmates and I had about feedback was that the "constructive criticism" was almost always generic stuff like "read more" or "you're doing great!" Unless they are operating at the level of an attending there has to be something they can improve on.

I think this is key, especially considering the fact that too many students get vague, generic feedback only to be slammed in written evals. Seeing that attendings on here themselves say that even interns/residents have a lot to learn, there isn't much justification for students to get vague feedback.

 

[operaman]

I think this is key, especially considering the fact that too many students get vague, generic feedback only to be slammed in written evals. Seeing that attendings on here themselves say that even interns/residents have a lot to learn, there isn't much justification for students to get vague feedback.

I tend to write vague feedback simply because I work so little with any one student that I don’t really have enough interaction upon which to base things. I do a lot of feedback verbally in the moment while I’m thinking about it but I find it challenging to find something to write a week later. There’s also the issue that most students are doing fine and gradually moving along in the process of becoming a physician and simply saying “continue to read and learn from your patients” is honestly the only constructive thing to say.

I also give everyone perfect marks on their evals unless they set a new standard of terrible. That’s my own personal protest of the inane grading we do for students.

Maybe people in the core clerkships have more time with each student and can actually offer comprehensive feedback. I’m just not creative enough to come up with something brilliant after spending less than an hour with a student.

 

[Lawpy]

I tend to write vague feedback simply because I work so little with any one student that I don’t really have enough interaction upon which to base things. I do a lot of feedback verbally in the moment while I’m thinking about it but I find it challenging to find something to write a week later. There’s also the issue that most students are doing fine and gradually moving along in the process of becoming a physician and simply saying “continue to read and learn from your patients” is honestly the only constructive thing to say.

I also give everyone perfect marks on their evals unless they set a new standard of terrible. That’s my own personal protest of the inane grading we do for students.

Maybe people in the core clerkships have more time with each student and can actually offer comprehensive feedback. I’m just not creative enough to come up with something brilliant after spending less than an hour with a student.

At least there is consistency in your approach. It's just disappointing when vague feedback is coupled with poor eval scores.

 

[mimelim]

Will obviously repeat what others have said, but will do my own sort of 'complete' 2 cents. Been involved with teaching medical students in one way or another for the last decade. The majority of people were on surgical clerkships and more recently mostly MS4s on Sub-Is.

#1 Expectations - I meet with the students at the start of the rotation. I tell them that I expect them to get a lot of my rotation regardless of who they are or what their career aspirations may be. First, the general stuff, I expect everyone to be on time. I show up early, I expect them to show up early. I expect that if there is nothing going on, that they should leave and be doing something else. I expect that they will roll with the punches as in, vascular surgery is notoriously unpredictable and sometimes that means that their schedules are going to be unpredictable and sometimes unequal. I make an effort to be fair and pragmatic, but I am far from perfect and there are things beyond my control.

I expect that all students put in time and effort into their morning rounds. I try to avoid students of any level seeing more than 3-4 patients in the morning. I expect the students to budget time appropriately and show up early enough to get their patient's seen and numbers collected. I expect them to learn from previous days how long they take and adjust accordingly. I expect all students to have a plan for the patient that day. I don't care if you are a new MS3 or not, you learn by putting things together yourself, not being told. I will spend time developing that skill with you, but I won't spoon feed it to you.

#2 Procedures - I expect all students rotating with me to have knots all over their scrub bottoms. I expect that you have the basics of suturing down before you show up in the OR. If you don't, I will go over things with you after you watch certain requisite youtube videos. I will give you endless suture, grafts, and instruments outside of the OR. I am comfortable with students doing good portions of surgeries with me. I will hand the prolene over to students and let them sew portions of anastamoses or ligate things. I will leave students alone in the OR to close skin. (with a scrub that I trust assisting them and watching them, and always coming back to check on them). Everything is a stepwise process. The more you scrub and the more prepared you are, the more you are going to do. I will talk your head off in the OR. I think that I have a lot to teach in every case that I do. But, I'm not going to teach things that I know can be learned outside of the OR. That is simply not fair to my patient. If you are interested in learning to place central lines, I expect that after a month on our service, you would feel comfortable placing a line by yourself, MS3 or 4. I expect that you will watch the requisite youtube video, watch a resident place a line, assist with the back table on 2-3 lines, do everything but puncture in another 2 or so lines and then on the 5th or 6th be attempting ultrasound guided puncture. Since I was a PGY3, I have always allowed students to do the lines with me. Bottom line, I make it clear, you get what you put in.

#3 Pimping - I hate pimping. I like asking questions and discussing things. If something is a "what am I thinking?" kind of question, I will tell them so and move on quickly. There is a tremendous amount of book knowledge that you must accrue, but I don't think there is a ton of utility in testing it on the fly at random moments. I prefer questions that I hope will stimulate students to recognize what is going on in front of them or focus them on important details of what we are doing.

#4 Feedback - I try to ask students after a couple weeks how they are doing. In person I tend to give point blank, brutal honesty feedback. My mantra is that all of them should be chasing perfection, but also realize that it is impossible to achieve. I think that I was a really good MS3, MS4, intern, junior resident and senior resident. But, I take more pride in my students becoming better than I was at each of those steps. "Only a man exceedingly proud and vain, would believe that his heir should be like himself, rather than like who he wished that he could be." For formal feedback, unless someone is terrible, I tend to be generous with the number grading, knowing that it matters little.

The caveat to all of this is that I am in a surgical sub-specialty. And because of where I am and have been, the majority of students I interact with choose to be where they are rotating, rather than forced as a part of a clerkship.

 

[Black Coffee 24/7]

Thank you for taking the time to make a thread like this! Speaking only for myself, I love when I get an opportunity to learn and practice universally useful, "high yield" things for clinical practice. For example, interpreting ECGs, x-rays, etc. and going through bread-and-butter illnesses relevant to the specialty beyond textbook/shelf knowledge. I also think that being very open about your expectations and how you grade is unbelievably useful to medical students - everyone has at least one story about how they got blindsided by an evaluation of straight 2/4 or 3/5 despite getting great verbal feedback.

God damn, brah. I'm glad I'm not the only one in the country by getting bent over by female preceptors in stereotypical passive aggressive fields out there.

 

[Black Coffee 24/7]

Few questions:

1. Brand new as in starting 3rd year, or as in starting a new rotation?
2. What is the structure of the inpatient team at your institution? That will make a huge difference in their experience.

In my residency, we had 2-4 interns per team that divided the workload evenly. The seniors usually managed the admits in the morning, and then distributed them to the interns in the afternoon after rounds. Med students were also primarily responsible for admissions and for carrying 1-3 patients day to day (depending on acuity, census, and experience/trust level). So the senior would do the bulk of the teaching with the new admits and the interns were more responsible for the teaching on the patients day to day (including preparing their student to present on rounds). It became more challenging to teach them in my third year because the structure of the clerkship changed so that the students left by 3pm each day, and only stayed on a service for 2 weeks, during which they likely missed several days due to rotating on nights, so there rally wasn’t time to build rapport and trust with the students.

In general, my suggestions are as follows:
1. Try to have one med student paired with one intern. It gets chaotic when they try to run plans by you in the morning if they’re trying to find 3 different interns.
2. Have them present to you after they preround. Throughout the rotation, they should go from reporting information to you, to synthesizing all the information into a diagnosis, to coming up with broad management plans (they should not be expected to know drug doses, but it’s reasonable for them to attempt to choose an antibiotic that would be useful in the clinical scenario). Challenge them to do so, but emphasize that it is a safe space—that’s why they are presenting to you before they present to the whole group. The goal is for them to do all the presenting and for you to chime in with “I agree” on rounds.
3. Offer teaching points in the minute. For example, you have a kid with bronchiolitis... discuss how the lung exam may be different in a kid with bacterial pneumonia. Or in a fever in a neonate, discuss how age may impact management.
4. Take them back with you when you reassess the patients in the afternoon and talk to the families. Even if they are just shadowing during that time, it’s useful to see.
5. If you’re doing an admission together, give them one task to focus on that you can offer feedback about after the encounter. For instance, if you’re admitting a kid with bronchiolitis, review the important questions to ask as part of the HPI and give them feedback on that at the end. Or have them focus on the exam while you gather the history.

There’s a teaching concept called minute preceptor or something along those lines. That offers good examples of how to give small teaching points in the context of patients without getting bogged down with giving an entire lecture. I’m still working on my teaching abilities, but doing that goes a long way.

A+++ method right now.

Got this whole treatment of points 1-5 on an inpatient service during my FM rotation. Arguably one of the best rotations so far for me despite me having zero interest in FM.

I'm very jealous of students having you as a preceptor.

 

[Black Coffee 24/7]

I think this is key, especially considering the fact that too many students get vague, generic feedback only to be slammed in written evals. Seeing that attendings on here themselves say that even interns/residents have a lot to learn, there isn't much justification for students to get vague feedback.

I also want to rant a little bit about something similar. There's no damn reason for any attending physicians to slam especially MS III for lack of clinical knowledge on evals. That's utterly malicious and badly reflects those programs' preceptors and residents. MS IIIers aren't supposed to know jack.

 

[NotaCop]

tbh the best thing you can do for an MS3 is send them home asap so they can study for the shelf

RT

 

[bananafish94]

God damn, brah. I'm glad I'm not the only one in the country by getting bent over by female preceptors in stereotypical passive aggressive fields out there.

Wait a second I didn’t say anything like that

 

[doyouhaveaflag]

I also give everyone perfect marks on their evals unless they set a new standard of terrible. That’s my own personal protest of the inane grading we do for students.

I do the same, for the same reasons.

I learn best by getting pimped, so that's the method I use to teach med students now. I do it in a gentle and non-judgemental way though and make it more part of a conversation where I can fill in any gaps they have in level-appropriate topics. I don't ask random factoids typically.

I also try to teach useful skills that all M3s should be able to do after a surgical rotation, like knot tying and suturing. Anytime I have a few minutes I'll watch them do it and give pointers. I always give students extra suture and ties that I carry around. I actually had one girl refuse them, saying "oh, I already know how to do that". I have to say, she did not get full marks on her eval. I also ask the med students to do small things like pull drains. Alarmingly few students that rotate with me have ever pulled a drain before, even after rotating on other surgical services. The med school associated with my program doesn't seem to allow as much hands-on experience as mine did. It also coddles the students in a way I think is detrimental to them, but that's a discussion for a separate thread.

I will say I put a lot more into teaching if the student puts some effort in. I'm a plastics intern and spent the last few months on plastic surgery, and there is certainly a subset of M3 students who choose to rotate on plastics because they think the hours will be better/it will require less effort than other rotations. One student even point blank said as much. I don't make much effort to teach those who show up to OR not knowing anything about the patient or the procedure we're about to do.

 

[Goro]

God damn, brah. I'm glad I'm not the only one in the country by getting bent over by female preceptors in stereotypical passive aggressive fields out there.

For someone who just came off of probation, I guess coffee didn't learn his lesson.

 

[LM75]

For someone who just came off of probation, I guess coffee didn't learn his lesson.

Well, they have good company...because neither did you.

 

[The Knife & Gun Club]

On IM I had an amazing intern - the kind you just know is going to go into academics/teaching one day.

He used to do “chalk talks” where 2-3 afternoons a week he’d give a simplified approach to a topic to help us students better understand a topic. Usually like a 15 minute lecture on how to interpret LFTs or work up a metabolic acidosis.

He’d draw a little diagram or flow chart while he talked and then left us with the chart to add to our notes.

 

[BigRedBeta]

Late to this thread and on a flight right now. Will come back to this later today

 

[mvenus929]

I don't make much effort to teach those who show up to OR not knowing anything about the patient or the procedure we're about to do.

When I was on my surgery rotation as an MS3, I did trauma surgery. It was rather slow on service, and our attendings that weren’t on service would do gen surgery cases. One day, I got told by the chief in the service to go down to OR5, where Dr. X was requesting me (to drive the camera in his case). I knew nothing about what procedure we were going to do, nor which patient we were going to do it on and by the time I got down to the OR, they were expecting me to scrub in.

The resident also scrubbed in on the case kept getting mad at me for not knowing anything about the case and minimal things about the procedure. I tried to explain that I found out about the case 5 minutes before I showed up and had no way of knowing I was going to be involved in said case, so therefore didn’t study anything about it or look up the patient.

 

[doyouhaveaflag]

The resident also scrubbed in on the case kept getting mad at me for not knowing anything about the case and minimal things about the procedure. I tried to explain that I found out about the case 5 minutes before I showed up and had no way of knowing I was going to be involved in said case, so therefore didn’t study anything about it or look up the patient.

Then that resident was a dick. That happened to me multiple times as a med student as well. I was referring to the students we have for a few weeks on service who know what their cases will be in advance. We always tell them the night before and are understanding if the schedule changes. But c'mon, there's no excuse for not knowing anything about the case if you knew you were assigned to it the day before.

 

[deleted645092]

I’m only halfway through third year right now but so far I think I’ve had the full range of rotations experiences ranging from purely shadowing to being left alone in the hospital after early morning rounds to do follow-up rounds and reassess 20+ patients, so I’ll add my perspective on the really good preceptors vs. the not-so-good ones;

1) Don’t make your students shadow, but if there is ever a situation where they have to for whatever reason, make a point to teach them SOMETHING during the encounter. This might be a given but on my peds rotation it was mostly standing in the corner making funny faces to the kids so that they weren’t so stressed out while being examined. While this sucked, the preceptor did make a point of having me do certain exams on the kids; I told them on my first day that I wanted to practice ENT exams because I can’t visualize the TM for ****. So my preceptor had me look in most of the kids ears first, and tell her what I saw. By the end of the rotation I got much better at it, and even if it’s all I took from that rotation, it’s probably one of the most useful skills that many take for granted but students suck at.

2) Don’t dump off your students, and if you have to, know who you’re leaving them with. I can’t count the amount of times I got dumped off on fellows on a subspecialty IM rotation and the fellows didn’t know the expectations; I was supposed to take 1 new consult per day but the fellow would have me go study but forget to tell me when a new consult came in; or they didn’t want to teach and my day would be wasted studying anyways.

3) Have them see new consults/ patents, and actually go over those patients with them. On my first FM rotation I was asked to go and see every other patient and get the H&P. But when I would get back before I could even present the preceptor we would walk in and he would redo everything I’d just done, and I didn’t get to present. While he was good at teaching on our downtime and was otherwise a good preceptor, it was annoying that I didn’t have the chance to get feedback on my visit with the patients. But on other rotations when I would see a new consult, they would have me write up the H&P and then take a shot at the assessment and plan. They would then go over everything with me and give feedback on it. That feedback really helped me progress through the rotation and figure out what was important for management differences between the patients.

4) Establish expectations early. The best preceptors I’ve had made it known early about the level of involvement they expected of me. One wanted me to pre-round before I even met them for the first time and update them on their patients. She also expected me to read up on the surgical cases the night before so I could answer questions about the case. All of this was established before the rotation so that I could hit the ground running, rather than telling me expectations as we went along in the hospital vs. clinic vs. the OR.

5) Know your students. Some might be go-getters and want to hit the ground running, but others will be more timid and scared to ask to be involved. The problem with those who are timid is that it’s difficult to tell the difference between them and those who are just lazy and want to skate through the rotation on minimal effort. If you are a preceptor who likes students to see the patient first or have students do things like throw/ remove sutures, remove PEG tubes or drains, change dressings, etc, but they don’t ask if they can, offer it to them. If they say yes, they may have just been timid, but if they say no or don’t seem excited, they may just be lazy. Some students are just timid to start because they’re nervous, but others may be afraid of seeming overly enthusiastic, and our perception is that there is a fine line between being being interested/ wanting to learn skills, and being overbearing.

 

[Adventurer753]

Will obviously repeat what others have said, but will do my own sort of 'complete' 2 cents. Been involved with teaching medical students in one way or another for the last decade. The majority of people were on surgical clerkships and more recently mostly MS4s on Sub-Is.

#1 Expectations - I meet with the students at the start of the rotation. I tell them that I expect them to get a lot of my rotation regardless of who they are or what their career aspirations may be. First, the general stuff, I expect everyone to be on time. I show up early, I expect them to show up early. I expect that if there is nothing going on, that they should leave and be doing something else. I expect that they will roll with the punches as in, vascular surgery is notoriously unpredictable and sometimes that means that their schedules are going to be unpredictable and sometimes unequal. I make an effort to be fair and pragmatic, but I am far from perfect and there are things beyond my control.

I expect that all students put in time and effort into their morning rounds. I try to avoid students of any level seeing more than 3-4 patients in the morning. I expect the students to budget time appropriately and show up early enough to get their patient's seen and numbers collected. I expect them to learn from previous days how long they take and adjust accordingly. I expect all students to have a plan for the patient that day. I don't care if you are a new MS3 or not, you learn by putting things together yourself, not being told. I will spend time developing that skill with you, but I won't spoon feed it to you.

#2 Procedures - I expect all students rotating with me to have knots all over their scrub bottoms. I expect that you have the basics of suturing down before you show up in the OR. If you don't, I will go over things with you after you watch certain requisite youtube videos. I will give you endless suture, grafts, and instruments outside of the OR. I am comfortable with students doing good portions of surgeries with me. I will hand the prolene over to students and let them sew portions of anastamoses or ligate things. I will leave students alone in the OR to close skin. (with a scrub that I trust assisting them and watching them, and always coming back to check on them). Everything is a stepwise process. The more you scrub and the more prepared you are, the more you are going to do. I will talk your head off in the OR. I think that I have a lot to teach in every case that I do. But, I'm not going to teach things that I know can be learned outside of the OR. That is simply not fair to my patient. If you are interested in learning to place central lines, I expect that after a month on our service, you would feel comfortable placing a line by yourself, MS3 or 4. I expect that you will watch the requisite youtube video, watch a resident place a line, assist with the back table on 2-3 lines, do everything but puncture in another 2 or so lines and then on the 5th or 6th be attempting ultrasound guided puncture. Since I was a PGY3, I have always allowed students to do the lines with me. Bottom line, I make it clear, you get what you put in.

#3 Pimping - I hate pimping. I like asking questions and discussing things. If something is a "what am I thinking?" kind of question, I will tell them so and move on quickly. There is a tremendous amount of book knowledge that you must accrue, but I don't think there is a ton of utility in testing it on the fly at random moments. I prefer questions that I hope will stimulate students to recognize what is going on in front of them or focus them on important details of what we are doing.

#4 Feedback - I try to ask students after a couple weeks how they are doing. In person I tend to give point blank, brutal honesty feedback. My mantra is that all of them should be chasing perfection, but also realize that it is impossible to achieve. I think that I was a really good MS3, MS4, intern, junior resident and senior resident. But, I take more pride in my students becoming better than I was at each of those steps. "Only a man exceedingly proud and vain, would believe that his heir should be like himself, rather than like who he wished that he could be." For formal feedback, unless someone is terrible, I tend to be generous with the number grading, knowing that it matters little.

The caveat to all of this is that I am in a surgical sub-specialty. And because of where I am and have been, the majority of students I interact with choose to be where they are rotating, rather than forced as a part of a clerkship.

This sounds like a rotation I need to be a part of next year...

 

[BigRedBeta]

Alright, so week late and probably more than a dollar short...

#1 - set expectations. I think that's the number one thing for much of life. Be as clear as you can about what you want students to do while they are on rotation with you. If you want them to see patients before you do, tell them, if you want them to present to you before rounds start for the practice (and to speed up rounds), tell them. This is especially true if there is something slightly outside the norm that you want to incorporate into your teaching so that they know what to expect. It's also important to tell them what you don't care about in case they are the type who want to try to impress you. For example, I told them I didn't care what time they came in every day so long as they got their work done - I still had the occasional student brag about having been there since 530a but I told them that it wasn't going to play a role in my eval.

#2 - have some pre-packaged chalk talks that you can bust out when there is down time. I personally hated as a student when residents would say "what do you want to learn about today?" without any warning (especially early on in the clerkship when I was still getting my feet under me). Worse was when I did have something to ask and they were completely unprepared to discuss the topic I chose. Even more terrible were the busy residents who would would ask me what I wanted to talk about today, not want to talk about that topic and do the ole' "that's a great topic, why don't you read up on that tonight, and give us five minutes about it tomorrow?". Having 4-5 different things that you can talk about readily saves everyone from those types of interactions. Ideally, the topics are something that you can talk about anywhere from 5 -20 minutes (or longer) depending on the amount you have free. If you can incorporate a number of different case scenarios for each, that also is helpful. My best topic was "wheezing in the pediatric patient" in which I could branch off into asthma, bronchiolitis and foreign body case scenarios. From there it was discussion about physiology, treatment options, presentations, workups and on and on. If I did the whole thing with an interested group of student, I could talk for probably 2+ hours. Additionally, I would try to make your chalk talks as interactive as possible and also as broadly applicable as possible - at least a common thing in your field, but if you can come up with a topic that hits a number of other specialties it will keep more people interested - sepsis is a good example of something I would talk about that applied to Peds, Surgery, IM and OB/Gyn.

#3 - Give homework so long as it is relevant, short, and not something you are going to be a hard*** about. If you do have specific things you want covered, tell your students to look into that. Nothing worse than being told to "look up condition XYZ" with no further details and spend all your time reading about treatments when your resident only wants to talk about work up/crazy new diagnostic testing only available in Europe.

#4 - Be excited about your field! Even if you are doing IM because you only want to be a gastroenterologist and the rest of the field is boring to you, at least show that you find some part of your job stimulating. I vividly remember my intern on IM on the first day of the rotation saying "don't you just hate med school? Can you even believe that it's only going to get worse because you just move up to be an intern?" He redeemed himself later in the rotation, but it was such a sour note to start on, and left me and my fellow med student in a really difficult spot for a rotation that was already stressful.



@thecerebellum If you want more tips, send me a PM