I suck at rotations

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Well, the implication that spending loads of time in the patients' room is the only path to putting the patient first probably won't go over too well. Are you helping the team get documentation, orders, and other work (you know, the stuff that helps make patient care happen) done? Is it possible that some of what you dismiss as chit chatting with the residents, is actually learning about what goes into clinical care, from basic "What tests do you order for this?" to "How do you get better at forming a differential?" Ignoring either of those things is not actually the way to "put patients first."

Now rotation evals are almost certainly subjective, and there is a significant amount of "playing the game" you will have to do. We've all done it. And as the medical student, you do have the most time to spend at the bedside, and should be there as much as you can while still accomplishing other necessary tasks. But I get the impression from your post that you may not yet have figured out what the most important things for you to be doing are.
 
leungdong said:
I am a firm believer in the patient coming first. For clinical rotations, I spend most of my time in the patient rooms going over lab results with them, disscusing plans, and addressing their concerns. However, many of my peers spend most of their time in the preceptor room and just study for their shelf. They spend more time chit chatting with the senior residents and get more attention. I asked for advice from my advisors and they just told me to "be myself" and "be interested". I would prefer not to cut down on patient time, but I guess that's what subjective medical education grading requires us to do on rotations. Any thoughts out there?
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Sounds like you are doing more RN duties than anything.
Post above me I think has your answer.
 
So you're worried that your buddies will score higher on the shelf exams because they get more didactic time? You can makeup study time but there's no substitute for facetime with patients my friend.
 
Like everything else in life you need to strike a balance. Unfortunately your job as a medical student is not to provide patient care, its to learn medicine. Sitting around talking about labs and concerns may be improving your communication skills but you also need to be reading, studying, and talking about patients with your attending and other students...i.e. not spending time with patients.
 
leungdong said:
I am a firm believer in the patient coming first. For clinical rotations, I spend most of my time in the patient rooms going over lab results with them, disscusing plans, and addressing their concerns. However, many of my peers spend most of their time in the preceptor room and just study for their shelf. They spend more time chit chatting with the senior residents and get more attention. I asked for advice from my advisors and they just told me to "be myself" and "be interested". I would prefer not to cut down on patient time, but I guess that's what subjective medical education grading requires us to do on rotations. Any thoughts out there?
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Whoa, whoa, whoa. First off it is not the job of a medical student to do these things. You are going to get into a lot, and I mean a lot, of trouble down the line if you are routinely doing this. (Unless your attending/resident has already discussed these things with the patient) Know what your responsibility is as a student. It should be discussing these things with the resident, before doing it with the patient.
 
leungdong said:
I am a firm believer in the patient coming first. For clinical rotations, I spend most of my time in the patient rooms going over lab results with them, disscusing plans, and addressing their concerns. However, many of my peers spend most of their time in the preceptor room and just study for their shelf. They spend more time chit chatting with the senior residents and get more attention. I asked for advice from my advisors and they just told me to "be myself" and "be interested". I would prefer not to cut down on patient time, but I guess that's what subjective medical education grading requires us to do on rotations. Any thoughts out there?
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Patient coming first doesn't necessarily mean spending all your time at the bedside teaching them things. Imo learning how to formulate an A&P (by talking with your senior/intern) is a better use of your time. After all, the more you learn about that stuff the better off all your future patients will be. Holding the pt hand while they're in the hospital may benefit the 5 patients you see everyday, but you're missing out on educational opportunities because of it.

Plus I really don't see how you can accurately provide so much info to the pt that you're spending a ton of time with them everyday. Before I leave a pt I always ask if I can do anything for them or answer any questions. Most of the time I end up telling them that I'll let the attending/senior know and we will discuss it later on rounds.
 
I've had a week of my IM rotation, and I have rarely discussed lab/test results directly with the patients. The most interaction that I have with the pt. is the history and physical. After doing an full or focused H&P I talk to the resident/attending about assessment and plan, and then they discuss it with the patient with me in the room to observe (their assessment & plan often varies greatly from mine though, lol 😉
 
who do you think is going to be a better doctor? someone who read about a ton and knows about disease and can formulate an a&p or someone who mucks around explaining lab values? you get almost nothing out of discussing with patients. not that it's a bad thing but what do you even say? "oh here's your sodium, it's 140 that's normal, here's your potassium 4.0 also normal but if it was off then we would worry about your heart blah blah blah"

what the residents see: your classmates are in the room with them, diligently studying or asking questions to learn more about being a doctor
you are nowhere to be seen
who do you think is going to get a better eval?
 
If you are spending so much time with your patients that it is making an obvious difference in how long you are spending with the team, then you are spending too much time. It's one thing to be thorough and do a good job, but you also need to be able to communicate efficiently. No one will ever want you on their team at this point or in residency if it takes you an hour to get one H&P.
 
Yeah,
My only shining moment where I truly spent too much time caring for a patient was at the VA where the guy needed a mask for his apnea and the respiratory therapist weren't answering calls. It was Friday. And the patient wasn't the best or compliant with our care. I spent hours going to the RT office to get them up there and get him his mask so he could leave.
I finally come back to the team room and everyone is like "where the hell were you?"
I told them.
They cheered.
 
Kaustikos said:
Yeah,
My only shining moment where I truly spent too much time caring for a patient was at the VA where the guy needed a mask for his apnea and the respiratory therapist weren't answering calls. It was Friday. And the patient wasn't the best or compliant with our care. I spent hours going to the RT office to get them up there and get him his mask so he could leave.
I finally come back to the team room and everyone is like "where the hell were you?"
I told them.
They cheered.
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Yea- time spent helping accomplish patient care is appreciated. Time spent talking to the patient just to talk is not.

@leungdong: As others have mentioned: doctors spend a small amount of their day with patients. In surgery, the bulk of our day is in the OR or rapid fire consults/traumas etc. medicine spends the bulk of their day writing long H&Ps and pontificating. As a student, it's important that you learn how to function the way your team does. Spending a ton of time with each patient might be fun, but not efficient. You can't do that as a resident so it's best to get into the habit of spending as little time with the patient as necessary to provide the most excellent care possible.

Finally: anytime a junior trainee (student or resident) proclaims their philosophies out loud, you come across as rigid. Early in training, you're supposed to be flexible and open to learning how others do things. You can't already be set in your ways. Coming here and telling us how you insist on "putting patient care first" which to you means spending your day in the patient's room rather than what you're supposed to, then being upset that your philosophy isn't being appreciated by your evaluators, speaks to some lack of insight. This can hurt you down the road, especially in any hierarchical specialty.
 
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Just remember: As a medical student, your presence/absence is NOT detrimental to the patient's safety/care. You are training; you are preparing to "fill the shoes" (eventually) of the physicians above you. Medical students DO tend to underestimate the importance of patient education. However, DO NOT fool yourself into thinking that you either have to be: A) Studying for boards, B) Socializing with residents/attendings, or C) Educating your patients.

As you are preparing to become a resident, you have to push yourself to become more efficient (don't waste time). You can still educate patients but don't roll in the dry-erase boards! Find your team and do what you can to help carry the load. Each day, pick a topic (e.g. "Pancreatitis--from onset to cure.") Know the presentation, know the work-up, know the treatments/complications, etc. THEN, look for a patient with a history of (Pancreatitis). Go to them and let THEM TEACH YOU about their experience! Patients usually love to talk about their problems!!

You can ask the hospitalists/radiologists/nurses/janitors to give you a name of a patient that has (pancreatitis). Look up their images, labs, etc. Attendings/Residents DO NOTICE you running around, digging **** up. In my experience, the Radiologist gave my attending a list of other patients with (one of my topics). When he asked, "what in the hell is that for?", he was pretty surprised that I was taking the initiative.

My attendings also have a rule: "if your patient leaves their room, you better be going to the same place". Follow them to Radiology/GI Lab/Cath Lab/Surgery/Physical Therapy/Pathology (if you can't be in surgery but know a "part of them" is going to be sent there)/etc. You can really log some serious "patient hours" by doing stuff like that... ADDED BONUS: you can report results BEFORE they get transcribed/placed on the chart.
 
leungdong said:
I am a firm believer in the patient coming first. For clinical rotations, I spend most of my time in the patient rooms going over lab results with them, disscusing plans, and addressing their concerns.
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So Satisfactory Pass or Marginal Pass?
 
leungdong said:
I am a firm believer in the patient coming first. For clinical rotations, I spend most of my time in the patient rooms going over lab results with them, disscusing plans, and addressing their concerns. However, many of my peers spend most of their time in the preceptor room and just study for their shelf. They spend more time chit chatting with the senior residents and get more attention. I asked for advice from my advisors and they just told me to "be myself" and "be interested". I would prefer not to cut down on patient time, but I guess that's what subjective medical education grading requires us to do on rotations. Any thoughts out there?
Click to expand...

To get good evals ... you show up appearing interested (even if you are not). Help the intern/resident out with dispo issues (social work, tracking down consultants), know your 1-3 patients really well and are easy to find (through text messaging).

You have to change your attitude or you are going to P every rotation. Do you really think you are putting patient's first just by being in their room all the time talking to them about lab work or test that you may not fully understand? Frankly, I am insulted with the "I am a firm believer in patient coming first .... I spend most of my time in the patients rooms ..."
 
lazymed said:
Yea- time spent helping accomplish patient care is appreciated. Time spent talking to the patient just to talk is not.

@leungdong: As others have mentioned: doctors spend a small amount of their day with patients. In surgery, the bulk of our day is in the OR or rapid fire consults/traumas etc. medicine spends the bulk of their day writing long H&Ps and pontificating.
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loool. In the case of some IM hospitalists I have seen, they spend half their time asking other physicians to figure out a problem. Seriously are internists no longer allowed/suddenly unable to work-up anything these days or does every abnormal lab value or complaint require a consult? OR perhaps it just makes more financial sense somehow? Then again not all are like this, but I just scratch my head wondering what an inpatient internist is supposed to do anymore.
 
Psai said:
what do you even say? "oh here's your sodium, it's 140 that's normal, here's your potassium 4.0 also normal but if it was off then we would worry about your heart blah blah blah"
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The thing I learned on my first day of M3 internal medicine rotation is that most patients don't even know why they are in the hospital to begin with. I wouldn't think "educating" them would be an easy or even reasonably quick task.
 
cbrons said:
loool. In the case of some IM hospitalists I have seen, they spend half their time asking other physicians to figure out a problem. Seriously are internists no longer allowed/suddenly unable to work-up anything these days or does every abnormal lab value or complaint require a consult? OR perhaps it just makes more financial sense somehow? Then again not all are like this, but I just scratch my head wondering what an inpatient internist is supposed to do anymore.
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A lot of consultants depend on consults, some specialists would be hurting otherwise. Also, for CYA purposes. Consultants are usually happy since they are getting paid extra, and a lot of times, it's probably better to have a specialist on board instead of mis-managing outside of someone's scope of practice in terms of ordering certain meds.
 
KnuxNole said:
A lot of consultants depend on consults, some specialists would be hurting otherwise. Also, for CYA purposes. Consultants are usually happy since they are getting paid extra, and a lot of times, it's probably better to have a specialist on board instead of mis-managing outside of someone's scope of practice in terms of ordering certain meds.
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Taken to an extreme this amounts to basically serving as a care manager instead of a physician. Sounds awful actually.
 
Your job on rotations is to do whatever the person who signs your eval would want you to be doing right then...your philosophy is not required nor requested when determining your job description
 
sb247 said:
Your job on rotations is to do whatever the person who signs your eval would want you to be doing right then...your philosophy is not required nor requested when determining your job description
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There's also the fact that as a rotating student, your philosophy should still be evolving.
 
cbrons said:
Taken to an extreme this amounts to basically serving as a care manager instead of a physician. Sounds awful actually.
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Yea a lot of interests function more like a resident for all the subspecialists. They follow up results and call the consultants and ask what they'd like to do.

I'm sure smaller community hospitals with less specialists available have a more involved role for IM docs.
 
leungdong said:
I am a firm believer in the patient coming first. For clinical rotations, I spend most of my time in the patient rooms going over lab results with them, disscusing plans, and addressing their concerns. However, many of my peers spend most of their time in the preceptor room and just study for their shelf. They spend more time chit chatting with the senior residents and get more attention. I asked for advice from my advisors and they just told me to "be myself" and "be interested". I would prefer not to cut down on patient time, but I guess that's what subjective medical education grading requires us to do on rotations. Any thoughts out there?
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Hi Dear, I feel sorry for this situation. You cannot change this world, but a piece of sincere advise, Go with the flow. But make a promise to yourself, when you achieve your MD license, you will make it up.
 
Somaira Azam said:
Hi Dear, I feel sorry for this situation. You cannot change this world, but a piece of sincere advise, Go with the flow. But make a promise to yourself, when you achieve your MD license, you will make it up.
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Here's where you're wrong: you absolutely CAN change the world. (See my note to incoming interns on my specialty forum.) OP's issue is having grand ideas about how medicine should be practiced, long before actually being in a position to make practice decisions. Spending half an hour going over labs (probably incorrectly) is not the job of an MS3 who is supposed to be learning the basics of clinical medicine. I don't care how warm and fuzzy it makes you feel to sit and chat, there is a time and a place. I often spend lots of time chatting with patients, talking about their social issues and all kinds of things, because I am the attending. I have residents running around doing all the other non-warm and fuzzy tasks that are essential to helping patients, like pre-op orders and calling consults. OP apparently wants to skip all that.
 
I agree with everyone else that you should be following your residents' example. Hanging out in the conference room and studying, especially if your residents get involved, can be great for learning and that helps your patients too. I had residents on internal who would sit there and do UWorld and MKSAP questions with us, and that was really helpful for talking through the harder questions and understanding those concepts.

Buff_Turf said:
You can ask the hospitalists/radiologists/nurses/janitors to give you a name of a patient that has (pancreatitis). Look up their images, labs, etc. Attendings/Residents DO NOTICE you running around, digging **** up. In my experience, the Radiologist gave my attending a list of other patients with (one of my topics). When he asked, "what in the hell is that for?", he was pretty surprised that I was taking the initiative.
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As a patient, I just had to comment about this. I know (as a student) that it is best to see medical conditions IRL to really understand them and differentiate real life from book knowledge. However, I was hospitalized a lot as a kid/teen, and a random resident looking me up and visiting me to chat about my weird medical problem X, which has happened to me multiple times, is invasive of my privacy. If you are on my team, or even like, you're on the B team and I'm a patient of the A team, I don't mind talking to you about my problems. But I'm in the hospital to get better, not to provide education to the whole hospital, and not to be a circus spectacle. So if you're not at all involved in my care and you found out about me from the janitor (really??????) you're going to get kicked out of the room.

As a medical student I would definitely appreciate the approach of doing more to combine the real patient with what the residents go over in didactics. It seems like this has worked well for you, but I just wanted to point out to you, and others that might make this suggestion, that not sticking to the patients on your team could be viewed as an invasion of privacy and intrusive in general. And you may have run into this already; I'm not trying to lecture you but it was really a personal pet peeve when residents did this to me.
 
I agree with ya, if some random person wanted to talk about my pancreatitis, I would want them out of my room.

Besides, there would be nothing to talk about. "Oh, I vomit a lot and hurt. Now can you give me more Dilaudid?"
 
hmockingbird said:
I agree with everyone else that you should be following your residents' example. Hanging out in the conference room and studying, especially if your residents get involved, can be great for learning and that helps your patients too. I had residents on internal who would sit there and do UWorld and MKSAP questions with us, and that was really helpful for talking through the harder questions and understanding those concepts.



As a patient, I just had to comment about this. I know (as a student) that it is best to see medical conditions IRL to really understand them and differentiate real life from book knowledge. However, I was hospitalized a lot as a kid/teen, and a random resident looking me up and visiting me to chat about my weird medical problem X, which has happened to me multiple times, is invasive of my privacy. If you are on my team, or even like, you're on the B team and I'm a patient of the A team, I don't mind talking to you about my problems. But I'm in the hospital to get better, not to provide education to the whole hospital, and not to be a circus spectacle. So if you're not at all involved in my care and you found out about me from the janitor (really??????) you're going to get kicked out of the room.

As a medical student I would definitely appreciate the approach of doing more to combine the real patient with what the residents go over in didactics. It seems like this has worked well for you, but I just wanted to point out to you, and others that might make this suggestion, that not sticking to the patients on your team could be viewed as an invasion of privacy and intrusive in general. And you may have run into this already; I'm not trying to lecture you but it was really a personal pet peeve when residents did this to me.
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Yeah I'd agree that this is ill advised. It's been made very clear to us not to open the charts of patients for whom we are not personally caring, which I think is a reasonable rule. Not to mention that if you have the time to look up random charts and go talk to patients who aren't on your team, it sounds like your residents are doing you a disservice in not either involving you more in your own patients' care or letting you go home.
 
Yeah, if you're just starting the year, this sounds like a failure in leadership. Your residents should be making expectations clear and giving you some guidance on how to invest your time. Now, if they did this and you ignored it, then you were stupid.

You will learn almost nothing by telling patients anything; you will learn a lot by asking them things. There's also a lot to learn in the scut work - the nuts and bolts of how you get patients from a to z. Scut shouldn't be the bulk of your time, but getting comfortable with it is important because it won't ever go away and eventually it will be your responsibility. The best thing you can do for your own learning is seeing new patients as they get admitted to your service, writing H&Ps, presenting them, reading about their condition, etc. There are times I can think of where sitting down to re-articulate the plan of care is important, but it shouldn't be the bulk of your time. If you're going to spend a half hour+ at the bedside, do it with the new CHF exacerbation in the ED who's getting admitted to your service and then help write the H&P.
 
I feel for you. I sucked at rotations too because IDGAF about shelf exams or rotations/residents I didn't like. Trust me, it can only make your match a hellish nightmare of anxiety if you get poor grades. Be practical unless you have nihilistic level of balls.

That said, I long ago promised myself that I'd do my career and my medical training my way, within reason. So F the man (and the residents). If you care about the grade, don't go that route. Play the game.
 
HelpPleaseMD said:
Frankly, I am insulted with the "I am a firm believer in patient coming first .... I spend most of my time in the patients rooms ..."
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I so want to make a joke, but I can't.
caffeinemia said:
I feel for you. I sucked at rotations too because IDGAF about shelf exams or rotations/residents I didn't like. Trust me, it can only make your match a hellish nightmare of anxiety if you get poor grades. Be practical unless you have nihilistic level of balls.

That said, I long ago promised myself that I'd do my career and my medical training my way, within reason. So F the man (and the residents). If you care about the grade, don't go that route. Play the game.
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You are very brave. Most of us can't do that, so any real abuse continues. Would be nice to know how much school name plays out on the residency trail beforehand, so then we can be ourselves and not play the game.
 
charmiedermie said:
I so want to make a joke, but I can't.

You are very brave. Most of us can't do that, so any real abuse continues. Would be nice to know how much school name plays out on the residency trail beforehand, so then we can be ourselves and not play the game.
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Well I just realized that medicine is not the end all be all. Even though we love to make our students and followers think so. Can you tell I'm a total anarchist and dislike authority/hegemony? Probably chose the wrong career huh?
 
caffeinemia said:
Well I just realized that medicine is not the end all be all. Even though we love to make our students and followers think so. Can you tell I'm a total anarchist and dislike authority/hegemony? Probably chose the wrong career huh?
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Oh I agree with you, it isn't. I don't know anyone who plays the game on rotations who genuinely likes playing the game. But if Honors is what is needed for getting a residency or a better residency, then you do what you have to do not to create waves, since it isn't worth destroying your career over someone you'll only be in contact with for 8 weeks. A lot of medicine hinges on having good, obedient foot soldiers and sometimes that continue in residency depending on field. I didn't do prelim Surgery for a reason. Lol.
 
The hard thing about rotations is that there are lots of unstated expectations. Besides learning everything you can (some of which will be applicable to the written shelf, some of which won't be), you should also want to be part of 'the team' and do what you can to help out. Every place is different, but the places I've been the 'unstated' med student expectations (that I picked up on, anyway) were:

1. Be early. Interview patients quickly in the morning. If there were concerns for the patient, give the resident a heads up.
2. "Get" lab values, rounding reports, OR schedules, clinic schedules. This highly varies, but I've had to write lab values, make rounding lists, and get the paper copies of the following day's schedule for my team. If it's an expectation, it's usually stated, though. Most of the time it's not just scut, it's actually helpful.
3. Make sure you know where to be. Don't make the resident chase you down to make rounding plans. Don't (in M3 anyway....) just ghost around 3:30.
4. If you are going to spend some *significant* time with patients, let the residents know, particularly if most down time is spent as a group. I'd have no idea if my med student were gone to play video games or gone to discuss the significance of the sodium of 134 with a patient - I'd just know that three other med students were there and one was missing.
5. Be interested. Ask appropriate questions.
6. Get your notes done and 'tis well if they are quickly done. Come up with a plan on your own.
7. Volunteer to help.
8. Don't poach patients.

Talking with patients is important - but don't be telling them things the resident or attending will have to be correcting later. And outside of morning and afternoon rounds, I'd be surprised if there were that many things to discuss that you should be spending 2-3 hours a day discussing topics with them.
 
Honestly, there were rotations where I deliberately spent time with patients to avoid my team.
I'd even jokingly tell patients that.
My ED rotation, for example, I hated this chief Resident with a passion. She was the most condescending and annoying person. I hated her. I spent my time away from her. Like, honestly, I saw more patients with her than any day just to avoid her. I annoyed her because I'd present two new patients when she was "busy". I loved it because she deserved it. She always chastised me for not doing things so I deliberately turned the table on her and presented patient after patient even when she was "busy". A courteous "**** you for being so horrible"
But I seriously do find a pseudo vacation seeing patients. It's like a lunch break but not counter where I talk to normal people. You just have to be smart about it. I don't think I'll stop doing it. Those 5 minutes with patients can be a relief from the hospital world because they're NOT hospital people.
 
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