Med school was going so well....until rotations. Advice?

[datpremedgirl]

Hey everyone, sorry for the long post ahead, but I just wanted to post on here to vent as well as ask for some advice. I started clerkships 6 months ago, and things have really not been going to way that I had been hoping for. During preclinicals, I studied extremely hard and sailed through every class, honoring all of my pre-clinicals. I thought, naively, that I could do well on rotations since I felt that I had a strong knowledge base and would be ready for all those pimp questions that would come my way (which, I have not gotten since literally none of my attendings have really pimped). I knew going into rotations however that I do tend to be on the more reserved side. I had extensively researched however on SDN that as long as I worked hard, showed interest, and asked questions, I could still garner some pretty good evals and honor my rotations.

Anyways, fast forward 6 months into clinicals, I have worked my butt off, but been so devastated by my grades so far. My only strength seems to be test-taking, and I have done over the 90th percentile on all of my shelves. However, my evaluations have been less than stellar and have dropped me down to high pass on one clerkship, and a pass on another despite my shelf exam scores (I only honored one rotation, and this was the one where evals didn't count). My evaluations are not particularly bad and I haven't gotten any terrible ones (as in I haven't received any negative comments, just the usual "read more, become more confident with assessment and plans, etc.") but they have just been so....mediocre. I get the usual "works hard, shows genuine interest in patients, enthusiastic, very motivated learner" but nothing that is "wow." No comments however about being quiet though, which I was most worried about. I range from around high 3's to low-4's (out of 5) on my evals. But, as I'm sure many of you know, even though a 3 = meets expectations, one needs at least a mid-4 or higher to honor rotations (a 3 is actually
below average at my school as most students tend to get 4's or higher. So, essentially, the average student tends to be in the "above average" range when it comes down to the numbers, which makes no sense). I get 3's on my fund of knowledge even though I am acing all the exams. I'm so sad that all the hard work I put into clinic and into doing well on the shelves (I sleep 4-5 hours a night because I study for 6 hours a day after coming home from work) is not reflected in my grades of "pass." I'm so exhausted and drained. I could have literally not tried so hard to study and done average on shelves, and still ended up with the same grades. I know I don't have a particularly charming or captivating personality which I believe plays a huge role on my eval scores; I'm just a reserved, hard-working medical student that tries her best. I'm at a loss right now of how to continue on with rotations, and am losing motivation to continue working so hard since it hasn't really seemed to make a difference. During pre-clinicals, my hard work reflected in my grade, but now they don't...

Looking ahead, if I were perform at an average level on the rest of my rotations, but I were to do well on Step 1 (which I take next spring), how would this look to residency directors (i.e. stellar preclinical grades, *hopefully* stellar step 1, but mediocre clinical grades)? I am not looking to go into anything too competitive such as derm or ENT, but I would like to match into a competitive program in a large city for a mid-tier specialty (such as emergency med, anesthesia, peds, etc.). I'm just so worried that my average clinical grades will drastically bring me down...how much of an effect will this have? I appreciate any advice, and apologize for making this post so long >.<

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[Donald Juan]

You should probably try and reach out to some of your superiors at your program to help you address this, especially with people you have rotated with (might check with your schools policy about this, some of them are sort of weird with addressing your eval to the person who gave it to you). Don't be afraid on rotations to ask what the expectations are at the beginning, and ask for feedback in midway to know what you need to improve on. But, if you are consistently getting below your schools average then there is some deficiency that is not clear from your post, and obviously you don't know what it is or you wouldn't be posting here. Everybody gets a random poor eval that isn't warranted, but 6 months in I wouldn't expect them all to be sub par.

 

[Snoopy2006]

Edit - how did you start M3 rotations without taking Step 1? I missed that on my first read.

The subjectivity of clinical rotation grades can be an issue. You're not alone. Many people have started threads like this. It also tends to vary from school to school. Some schools really try to be strict in their curves and others high pass everyone (this is reflected in the Dean's Letter for what it's worth, so programs are aware).

Does it matter? Well, yes, but how much depends on your particular situation and what field you apply into. Highly competitive specialties are more likely to look for consistently strong grades, especially honors in key rotations. Less of a big deal in other specialties but a string of just passes is never a good sign. Makes people worry about how someone will perform as a resident.

If this is a consistent theme, I think the bigger issue is to figure out how to improve. I've found a lot of med students say they're just not extroverted or assertive but in my experience that alone usually doesn't lower someone to the level of just pass. There are likely fixable issues here, the key is to find them.

If your attendings are giving you crappy generic feedback ask for a meeting with one who's a straight shooter and figure out ways to improve. I don't know you so this may not apply but here are things to consider:

1) Are you carrying a fair share of patients when prerounding? Are you reading on these patients and making sure your presentations to the team are well thought out? If you're struggling with your plan, run your presentation by your resident before rounds. Don't confuse book smarts with clinical smarts. There's huge overlap, but I knew plenty of students who did well on test day but struggled to come up with basic assessment and plans.

You talk about how you can't show your knowledge because of the lack of pimping, but your presentations during rounds are where you show your knowledge to the team.

2) Are you showing interest? Ask questions at appropriate times (not all the time) and ask insightful questions, not things that can be looked up easily. Be an active part of the team.

3) Are you helping the team? The worst students get in the way, the average students just passively stand around, but the best pay attention to what the team needs and find ways to pitch in.

Taking ownership of your patients can help. As an example: as an M3 I would take notes on the patient list during rounds just like the residents. I'd have check boxes for labs to follow up on, imaging, etc. I'd make sure when we ran the list in the afternoon I had updates for my residents.

4) Are you doing anything that could be construed negatively? This is the hardest for most students to answer because it takes self reflection most people don't want to do. Are you leaving as early as possible for the student lounge to study for those shelf scores instead of sticking around to help the team? All residents have been where you are and shouldn't waste your time, but there are some students who take it to the extreme and try to escape to go do practice questions as early as possible.

When a procedure or code comes up, do you ask to observe or go along (showing interest) or just stand on the side and wait to be told what to do? Have you been competitive with fellow students or collaborative? Do you show up on time?

I'm not extroverted by any means but I never had a problem showing interest on rotations. I found ways to help the team, asked questions when my residents were free, and looked for opportunities - if there was downtime and a code was going on, I was there. If our team was on standby and another resident I knew was getting ready to put in an art line, I asked to watch so the next time I could do one. When an peds intern had a medical emergency for a week I stepped up and carried 5 or 6 of her patients (which was a little much for an M3 but got me some of the best evals I've ever had). Be a part of the team, be friendly and normal, and look for opportunities.

Sometimes people are just stuck getting unfair evals. But if it's a trend, it's more likely you have deficiencies you're overlooking that can be addressed and improved.

 

[IMreshopeful]

As a fellow who has taught probably a couple dozen medical students directly over the last six years (probably more), I usually gave decent evals to my students and residents unless there was some critical deficiency (and I would always try to avoid screwing their grade at the end by talking to them if they were underperforming). This is what I think I realized.

1. If students showed an interest in learning, were engaged in patient care (whether its answering questions on rounds, talking to patients throughout the day and doing admissions, presenting to attendings, etc) the grade was usually good.
2. We know that you aren’t a resident and your knowledge base isn’t that of one. However it’s also incumbent on you when you’re carrying one patient or two (which is far less than what I did as a sub-I or MS3, I usually had 3-4 patients on wards or 2-3 ICU patients at any time depending on the service) to read as much as possible - diagnosis, management, complications, treatment nuances, differential etc
3. Some students rotated with me knowing they were going into a different specialty. Nevertheless they worked hard. So this doesn’t matter if you still show an interest and try to learn. I’ve heard claims of “bias” against other non IM bound students in this regard - I don’t think it’s usually true.
4. Be helpful - if there’s downtime talk to your residents and ask if there’s things you can do to help out their workday. Nobody wants to scut medical students out but part of patient care involves doing the boring things - faxes, prior auths, med rec, writing notes etc. As a subspecialty fellow I still have to do these things even between reading echos, caths, etc. Residents will always appreciate help in this.
5. Your attendings and residents should be giving you better feedback. Do not accept “read more” or “you’re doing fine”. Concrete advice is golden. I had issues on a rotation in residency and a fellow I was with pointed out frankly an issue that I was having - I immediately was able to rectify it. Sometimes you don’t realize what’s going on until you’ve actually had to have someone else say it to you.

Hope this helps

 

[Goro]

I'm getting the vibe that OP is trying too hard to impress. Thoughts?

Seeking feedback from your preceptors and your clinical Deans is going to be crucial for future success.

 

[Newyawk]

Edit - how did you start M3 rotations without taking Step 1? I missed that on my first read.

The subjectivity of clinical rotation grades can be an issue. You're not alone. Many people have started threads like this. It also tends to vary from school to school. Some schools really try to be strict in their curves and others high pass everyone (this is reflected in the Dean's Letter for what it's worth, so programs are aware).

Does it matter? Well, yes, but how much depends on your particular situation and what field you apply into. Highly competitive specialties are more likely to look for consistently strong grades, especially honors in key rotations. Less of a big deal in other specialties but a string of just passes is never a good sign. Makes people worry about how someone will perform as a resident.

If this is a consistent theme, I think the bigger issue is to figure out how to improve. I've found a lot of med students say they're just not extroverted or assertive but in my experience that alone usually doesn't lower someone to the level of just pass. There are likely fixable issues here, the key is to find them.

If your attendings are giving you crappy generic feedback ask for a meeting with one who's a straight shooter and figure out ways to improve. I don't know you so this may not apply but here are things to consider:

1) Are you carrying a fair share of patients when prerounding? Are you reading on these patients and making sure your presentations to the team are well thought out? If you're struggling with your plan, run your presentation by your resident before rounds. Don't confuse book smarts with clinical smarts. There's huge overlap, but I knew plenty of students who did well on test day but struggled to come up with basic assessment and plans.

You talk about how you can't show your knowledge because of the lack of pimping, but your presentations during rounds are where you show your knowledge to the team.

2) Are you showing interest? Ask questions at appropriate times (not all the time) and ask insightful questions, not things that can be looked up easily. Be an active part of the team.

3) Are you helping the team? The worst students get in the way, the average students just passively stand around, but the best pay attention to what the team needs and find ways to pitch in.

Taking ownership of your patients can help. As an example: as an M3 I would take notes on the patient list during rounds just like the residents. I'd have check boxes for labs to follow up on, imaging, etc. I'd make sure when we ran the list in the afternoon I had updates for my residents.

4) Are you doing anything that could be construed negatively? This is the hardest for most students to answer because it takes self reflection most people don't want to do. Are you leaving as early as possible for the student lounge to study for those shelf scores instead of sticking around to help the team? All residents have been where you are and shouldn't waste your time, but there are some students who take it to the extreme and try to escape to go do practice questions as early as possible.

When a procedure or code comes up, do you ask to observe or go along (showing interest) or just stand on the side and wait to be told what to do? Have you been competitive with fellow students or collaborative? Do you show up on time?

I'm not extroverted by any means but I never had a problem showing interest on rotations. I found ways to help the team, asked questions when my residents were free, and looked for opportunities - if there was downtime and a code was going on, I was there. If our team was on standby and another resident I knew was getting ready to put in an art line, I asked to watch so the next time I could do one. When an peds intern had a medical emergency for a week I stepped up and carried 5 or 6 of her patients (which was a little much for an M3 but got me some of the best evals I've ever had). Be a part of the team, be friendly and normal, and look for opportunities.

Sometimes people are just stuck getting unfair evals. But if it's a trend, it's more likely you have deficiencies you're overlooking that can be addressed and improved.

This is the "game" everyone refers to. Do all of these things and your evals will be golden. Its annoying af and its a lot of hard work that you know isnt really your job and you should be learning, not doing basic tasks to make the lives of paid residents easier.
The attendings care about knowledge mostly and presentations. Some are satisfied just by interest.
Residents want you to do as much work as you can. If you do more than any other student theyve seen and you do it well, youll see it reflected.

 

[operaman]

Sorry you’re having some trouble with this. I agree with other posters that your story likely reflects an ongoing issue and as such is amenable to fixing. I’m sorry you haven’t gotten better feedback from the people you rotate with. I’ll admit I suck at giving students feedback myself; I tend to praise the stellar ones and ignore the disinterested and I need to be better about it.

But yes, lots of good advice already. I’ll touch on a few things which might help:

1). Presentations. This is how attendings assess you. They should be memorized, concise, in the correct order, and include a solid attempt at an assessment and plan. There are subtle differences between services as to what they want done so ask early on. Always be prepared to give a full presentation but abridge appropriately. Don’t editorialize until the A and P. Expect to be stopped. Know more but say less. This is really where you demonstrate the skills you are learning, namely the ability to communicate with fellow physicians about patients.

2) rounding. Most students blend into the paint and emerge only to present their patient. Good students are taking notes and making check boxes just like their interns and residents. They do this for every patient on service just like the residents and they will help the team ensure things get done. This also spares you having to ask what you can do to help; just look at the list of checkboxes and ask if you can start working on xyz. I suck at thinking of tasks for students, but love it when a student will say something like “hey do you mind if I make some calls and get those outside records faxed over her?” Or “hey I saw that consult just got put in; can I grab you a scope and meet you at the bedside?” Or “mind if I go get started cleaning that wound you’re about to go repair?” Take a free hour and make sure the med rec and history in the chart are accurate by asking the patient and calling their pharmacy (this helps a LOT because the chart is often wrong). That proactive approach is what truly distinguishes the best students. There is ALWAYS work to be done. Find it.

3) appearances. Body language. Put on gloves when you enter any room so you’re ready to work even if you don’t end up doing anything. Anticipate needs in the room like light or supplied and make sure they’re available. Learn your chief’s preferred glove size and always have an extra pair in your pocket so you can just quietly hand them over if they need them. Make sure you STAY IN THE CIRCLE. Don’t stand outside the circle in rounds; be right in the thick of it. If a senior person is talking, your pen should be moving. Period. A few little tweaks can make you look a LOT more involved without risking being annoying. Nobody gets annoyed by students who quietly get work done and make everyone’s life easier by anticipating needs and meeting them.

 

[7331poas]

Edit - how did you start M3 rotations without taking Step 1? I missed that on my first read.

lots of schools take step 1 after clerkships

 

[solitarius]

Shocker.

Med school grinder with sub-mediocre communication and interpersonal skills.

 

[Rendar5]

I don’t see why you need to be freaking out. High pass is still a good grade. I got into my number 2 match with high pass in almost all my clerkships except for honors in the field I was interested in pursuing and maybe one other. Hard to remember 9 years ago.

That said if I followed operaman’s advice I probably would have had many more honors.

I only give honors to maybe 10% of students. Those that act like above typically get it.

 

[IMreshopeful]

This is the "game" everyone refers to. Do all of these things and your evals will be golden. Its annoying af and its a lot of hard work that you know isnt really your job and you should be learning, not doing basic tasks to make the lives of paid residents easier.
The attendings care about knowledge mostly and presentations. Some are satisfied just by interest.
Residents want you to do as much work as you can. If you do more than any other student theyve seen and you do it well, youll see it reflected.

Yes, surprise, residents like it when medical students help them out with work. Part of that is educational. Some of it is busy work. I’m not sure why it matters that the residents are paid and you aren’t - this isn’t grade school and you’re an adult learner - you have to be proactive and not just spoonfed information.

 

[sunshinefl]

Sorry you’re having some trouble with this. I agree with other posters that your story likely reflects an ongoing issue and as such is amenable to fixing. I’m sorry you haven’t gotten better feedback from the people you rotate with. I’ll admit I suck at giving students feedback myself; I tend to praise the stellar ones and ignore the disinterested and I need to be better about it.

But yes, lots of good advice already. I’ll touch on a few things which might help:

1). Presentations. This is how attendings assess you. They should be memorized, concise, in the correct order, and include a solid attempt at an assessment and plan. There are subtle differences between services as to what they want done so ask early on. Always be prepared to give a full presentation but abridge appropriately. Don’t editorialize until the A and P. Expect to be stopped. Know more but say less. This is really where you demonstrate the skills you are learning, namely the ability to communicate with fellow physicians about patients.

2) rounding. Most students blend into the paint and emerge only to present their patient. Good students are taking notes and making check boxes just like their interns and residents. They do this for every patient on service just like the residents and they will help the team ensure things get done. This also spares you having to ask what you can do to help; just look at the list of checkboxes and ask if you can start working on xyz. I suck at thinking of tasks for students, but love it when a student will say something like “hey do you mind if I make some calls and get those outside records faxed over her?” Or “hey I saw that consult just got put in; can I grab you a scope and meet you at the bedside?” Or “mind if I go get started cleaning that wound you’re about to go repair?” Take a free hour and make sure the med rec and history in the chart are accurate by asking the patient and calling their pharmacy (this helps a LOT because the chart is often wrong). That proactive approach is what truly distinguishes the best students. There is ALWAYS work to be done. Find it.

3) appearances. Body language. Put on gloves when you enter any room so you’re ready to work even if you don’t end up doing anything. Anticipate needs in the room like light or supplied and make sure they’re available. Learn your chief’s preferred glove size and always have an extra pair in your pocket so you can just quietly hand them over if they need them. Make sure you STAY IN THE CIRCLE. Don’t stand outside the circle in rounds; be right in the thick of it. If a senior person is talking, your pen should be moving. Period. A few little tweaks can make you look a LOT more involved without risking being annoying. Nobody gets annoyed by students who quietly get work done and make everyone’s life easier by anticipating needs and meeting them.

Love this! Saved it for myself.

 

[Newyawk]

Yes, surprise, residents like it when medical students help them out with work. Part of that is educational. Some of it is busy work. I’m not sure why it matters that the residents are paid and you aren’t - this isn’t grade school and you’re an adult learner - you have to be proactive and not just spoonfed information.

Yea, a very, very small part of it is educational. It matters because im paying to be educated not to do scut work. Im not suggesting we change the system but i am saying that residents shouldnt blame a student for preferring to read a textbook over running errands (the interns job, by definition).

 

[IMreshopeful]

Yea, a very, very small part of it is educational. It matters because im paying to be educated not to do scut work. Im not suggesting we change the system but i am saying that residents shouldnt blame a student for preferring to read a textbook over running errands (the interns job, by definition).

You sound like a joy to work with on wards.

Nobody is saying don’t study in downtime. That’s expected. However if there’s something that you can do to help your interns - particularly if it’s for YOUR patients (taking ownership of patients is another thing I expect of my medical students), then you should do it. You don’t have to love it. But you should do it. Facilitating care is just as important as doing a procedure or doing a history and physical. If your patient gets sick, go with the intern and evaluate the patient, etc. it’s not just about faxes and paperwork. That is part and parcel of everything.

This entitled attitude is what will give medical students bad grades. Your job is more than just preround - round with attending - go and sit in a library reading and doing Uworld. If you can’t see that, then I have nothing more that I can tell you

 

[IMreshopeful]

And FWIW when I was a medical student we rounded on all the patients amongst the three of us (with the interns), were expected to present everything, went to all of their procedures, aided in facilitating care - whether it was drawing blood, faxing crap, writing notes or helping with orders, and the expectation was to learn through self study AND through reading. Experience and direct patient care are just as important as flipping through a textbook for real life, not just an exam.

 

[Candidate2017]

I'm getting the vibe that OP is trying too hard to impress. Thoughts?

Seeking feedback from your preceptors and your clinical Deans is going to be crucial for future success.

No I get the vibe that she confuses studying really, really hard with working hard.

 

[Newyawk]

were clearly talking about different things and its my fault for the misunderstanding. I am not talking about patient care. I am specifically talking about minimally educational experiences like sending labs when the resident has little else to do and the student can easily be studying. and again, I understand its a team effort, but no resident should look down upon a student who doesn't volunteer to do scut work and is instead using that time to read up on their patients, etc. I have been in this situation before, when I was clearly using my time productively to learn and I was given menial tasks to do instead. I think I have a right to question the value of my education at that point. of course I always do the task for whoever asks me anyway. I am a joy to work with because I'm not a brown-noser and most of the residents Ive worked with appreciate that. ill offer to help them because I know it makes their life easier, not because I think thats what I should be doing. if I don't like them, however, I will ignore them entirely. if you're not interested in my education then **** off and I'm gonna do me. thats not being entitled.

maybe youre that resident that thinks a student should be sitting around at 3 PM when there is almost nothing else to do when you could send the student home to study and handle their business (the residents that do this realize that its not the students job to be sitting around, its theirs). I seem to jive well with those residents, not the anal ones who tell me I should be a brown-noser (i have literally heard this from one of my residents).

 

[Candidate2017]

This is the "game" everyone refers to. Do all of these things and your evals will be golden. Its annoying af and its a lot of hard work that you know isnt really your job and you should be learning, not doing basic tasks to make the lives of paid residents easier.

The purpose of clinicals is to transition you to the real world, where learning is on your own time. In the hospital, your job is to make everyone's job easier. From the janitor to the attending.

Med students mistakenly believe learning comes from occasional pearls dropped by the attendings. However the bulk of your learning comes from your direct seniors: your residents. Unlike the attendings, they remember what it's like to be in your shoes and can help guide you along the next steps. You learn from observation, actual teaching and work assigned to you by your residents. If you are not making your residents' lives easier, guess what? They'll neither have time nor inclination to actively teach you.

 

[operaman]

were clearly talking about different things and its my fault for the misunderstanding. I am not talking about patient care. I am specifically talking about minimally educational experiences like sending labs when the resident has little else to do and the student can easily be studying. and again, I understand its a team effort, but no resident should look down upon a student who doesn't volunteer to do scut work and is instead using that time to read up on their patients, etc. I have been in this situation before, when I was clearly using my time productively to learn and I was given menial tasks to do instead. I think I have a right to question the value of my education at that point. of course I always do the task for whoever asks me anyway. I am a joy to work with because I'm not a brown-noser and most of the residents Ive worked with appreciate that. ill offer to help them because I know it makes their life easier, not because I think thats what I should be doing. if I don't like them, however, I will ignore them entirely. if you're not interested in my education then **** off and I'm gonna do me. thats not being entitled.

maybe youre that resident that thinks a student should be sitting around at 3 PM when there is almost nothing else to do when you could send the student home to study and handle their business (the residents that do this realize that its not the students job to be sitting around, its theirs). I seem to jive well with those residents, not the anal ones who tell me I should be a brown-noser (i have literally heard this from one of my residents).

So yes, med students are there to learn and not be scutted out all the time. That’s what everyone says on paper. Then there’s the reality that while attendings may have formal teaching responsibilities, residents are not so straightforward. While we are told that part of our job is teaching med students, that is not the measure by which our faculty evaluate us. As such, most of us prioritize our other responsibilities by which we are actually assessed.

I don’t think most of us care about brown nosing. I care mainly about how proactive someone is and how invested they are in caring for our patients and learning about our field. The ones who show interest and demonstrate that interest by their hard work are the ones I end up teaching the most. This is both due to enthusiasm on my part to teach the ones who care as well as the simple fact that all the scut needs to be done and I will always prioritize scut over teaching. If someone helps me get the scut done, then I have time to teach the fun stuff.

All that said I totally understand students who elect to prioritize their own study rather than being a worker bee on the wards. I generally trust adult learners at this level to know themselves and what they have to do to succeed. I also don’t want to make someone feel obligated to listen to my pondering if they would rather be elsewhere. Only teaching the truly interested seems to avoid torturing the disinterested wih unwanted learning.

 

[Rads4lyfe]

3rd year is a game. Just need to play it right. Presentations need to be concise with appropriate assessment and plans. You don’t actually have to be THAT smart, but know how to seem smart.

Also, it helps to request attendings/residents that are known to give everyone 5/5 for evals and to suck up to the people giving you evaluations.

 

[Lnsean]

It's game...just do the dance or move out of the way so others can dance

 

[DOFOSHO]

Hey everyone, sorry for the long post ahead, but I just wanted to post on here to vent as well as ask for some advice. I started clerkships 6 months ago, and things have really not been going to way that I had been hoping for. During preclinicals, I studied extremely hard and sailed through every class, honoring all of my pre-clinicals. I thought, naively, that I could do well on rotations since I felt that I had a strong knowledge base and would be ready for all those pimp questions that would come my way (which, I have not gotten since literally none of my attendings have really pimped). I knew going into rotations however that I do tend to be on the more reserved side. I had extensively researched however on SDN that as long as I worked hard, showed interest, and asked questions, I could still garner some pretty good evals and honor my rotations.

Anyways, fast forward 6 months into clinicals, I have worked my butt off, but been so devastated by my grades so far. My only strength seems to be test-taking, and I have done over the 90th percentile on all of my shelves. However, my evaluations have been less than stellar and have dropped me down to high pass on one clerkship, and a pass on another despite my shelf exam scores (I only honored one rotation, and this was the one where evals didn't count). My evaluations are not particularly bad and I haven't gotten any terrible ones (as in I haven't received any negative comments, just the usual "read more, become more confident with assessment and plans, etc.") but they have just been so....mediocre. I get the usual "works hard, shows genuine interest in patients, enthusiastic, very motivated learner" but nothing that is "wow." No comments however about being quiet though, which I was most worried about. I range from around high 3's to low-4's (out of 5) on my evals. But, as I'm sure many of you know, even though a 3 = meets expectations, one needs at least a mid-4 or higher to honor rotations (a 3 is actually
below average at my school as most students tend to get 4's or higher. So, essentially, the average student tends to be in the "above average" range when it comes down to the numbers, which makes no sense). I get 3's on my fund of knowledge even though I am acing all the exams. I'm so sad that all the hard work I put into clinic and into doing well on the shelves (I sleep 4-5 hours a night because I study for 6 hours a day after coming home from work) is not reflected in my grades of "pass." I'm so exhausted and drained. I could have literally not tried so hard to study and done average on shelves, and still ended up with the same grades. I know I don't have a particularly charming or captivating personality which I believe plays a huge role on my eval scores; I'm just a reserved, hard-working medical student that tries her best. I'm at a loss right now of how to continue on with rotations, and am losing motivation to continue working so hard since it hasn't really seemed to make a difference. During pre-clinicals, my hard work reflected in my grade, but now they don't...

Looking ahead, if I were perform at an average level on the rest of my rotations, but I were to do well on Step 1 (which I take next spring), how would this look to residency directors (i.e. stellar preclinical grades, *hopefully* stellar step 1, but mediocre clinical grades)? I am not looking to go into anything too competitive such as derm or ENT, but I would like to match into a competitive program in a large city for a mid-tier specialty (such as emergency med, anesthesia, peds, etc.). I'm just so worried that my average clinical grades will drastically bring me down...how much of an effect will this have? I appreciate any advice, and apologize for making this post so long >.<

Everyone has personality - you just need to find the specialty that you fit in with. Look beyond medicine, peds, and surgery.

 

[ciestar]

Threads like this really get me thinking.
I struggled hard throughout pre-clinicals. My step 1 score is mediocre. However, my clerkships seems to be my time to shine. I am getting excellent feedback and I clicked well with the PD in the office and the site director already offered a strong LOR if my work continues the way it has been. This is my first rotation. I am always sure to ask to see as much as I can. I ask good questions and I am present as often as possible to get the practice in. I don’t ever make it seem like I am bored and my time would better be spent studying.

Puts more pressure on me for that darn shelf..but...

Yeah, it makes you think.

 

[Snoopy2006]

were clearly talking about different things and its my fault for the misunderstanding. I am not talking about patient care. I am specifically talking about minimally educational experiences like sending labs when the resident has little else to do and the student can easily be studying. and again, I understand its a team effort, but no resident should look down upon a student who doesn't volunteer to do scut work and is instead using that time to read up on their patients, etc. I have been in this situation before, when I was clearly using my time productively to learn and I was given menial tasks to do instead. I think I have a right to question the value of my education at that point. of course I always do the task for whoever asks me anyway. I am a joy to work with because I'm not a brown-noser and most of the residents Ive worked with appreciate that. ill offer to help them because I know it makes their life easier, not because I think thats what I should be doing. if I don't like them, however, I will ignore them entirely. if you're not interested in my education then **** off and I'm gonna do me. thats not being entitled.

maybe youre that resident that thinks a student should be sitting around at 3 PM when there is almost nothing else to do when you could send the student home to study and handle their business (the residents that do this realize that its not the students job to be sitting around, its theirs). I seem to jive well with those residents, not the anal ones who tell me I should be a brown-noser (i have literally heard this from one of my residents).

I think you're really taking things the wrong way.

What we're saying: Medical students who show an interest, stick around and look for educational opportunities (whether that's doing an admission, volunteering to observe and then perform a procedure, showing an interest in running the list with the residents and asking management questions) get good reviews. The great students look for opportunities. The mediocre ones look around and say, "No one assigned me a task, so I'm going to take off to study."

What you're hearing: Medical students who don't volunteer to track down outside records, help with paperwork, and work on scutwork will get bad evals from residents.

Here's an example: after rounds, we had a short break with no admissions. I was on my way to do an ABG and an M3 asked to come along and watch. The next time an ABG opportunity came up, she performed it herself. She could have taken off to go study for her shelf exam, but instead found an opportunity to learn something useful. If you consider that scutwork, I can't help you.

Get rid of the chip on your shoulder. Either you're just misinterpreting what we're saying, or you're that med student that thinks anything not "required" is scutwork.

For what it's worth, it goes both ways. The best residents are the ones who remain aware that med students are there to learn, should be given responsibility and not ignored, and also cognizant of the fact that they have shelf exams to take. I always did high-yield session with my students that was geared towards their shelves, and dismissed them early most days - as soon as it was clear nothing was going on. I also try to tailor the rotation to their specialty of interest, I can usually find some pearls or some things that will be relevant to their field. Too many residents get overwhelmed and don't make an effort to teach or forget what it's like to be a medical student.

 

[NeuResurgens]

Sorry you’re having some trouble with this. I agree with other posters that your story likely reflects an ongoing issue and as such is amenable to fixing. I’m sorry you haven’t gotten better feedback from the people you rotate with. I’ll admit I suck at giving students feedback myself; I tend to praise the stellar ones and ignore the disinterested and I need to be better about it.

But yes, lots of good advice already. I’ll touch on a few things which might help:

1). Presentations. This is how attendings assess you. They should be memorized, concise, in the correct order, and include a solid attempt at an assessment and plan. There are subtle differences between services as to what they want done so ask early on. Always be prepared to give a full presentation but abridge appropriately. Don’t editorialize until the A and P. Expect to be stopped. Know more but say less. This is really where you demonstrate the skills you are learning, namely the ability to communicate with fellow physicians about patients.

2) rounding. Most students blend into the paint and emerge only to present their patient. Good students are taking notes and making check boxes just like their interns and residents. They do this for every patient on service just like the residents and they will help the team ensure things get done. This also spares you having to ask what you can do to help; just look at the list of checkboxes and ask if you can start working on xyz. I suck at thinking of tasks for students, but love it when a student will say something like “hey do you mind if I make some calls and get those outside records faxed over her?” Or “hey I saw that consult just got put in; can I grab you a scope and meet you at the bedside?” Or “mind if I go get started cleaning that wound you’re about to go repair?” Take a free hour and make sure the med rec and history in the chart are accurate by asking the patient and calling their pharmacy (this helps a LOT because the chart is often wrong). That proactive approach is what truly distinguishes the best students. There is ALWAYS work to be done. Find it.

3) appearances. Body language. Put on gloves when you enter any room so you’re ready to work even if you don’t end up doing anything. Anticipate needs in the room like light or supplied and make sure they’re available. Learn your chief’s preferred glove size and always have an extra pair in your pocket so you can just quietly hand them over if they need them. Make sure you STAY IN THE CIRCLE. Don’t stand outside the circle in rounds; be right in the thick of it. If a senior person is talking, your pen should be moving. Period. A few little tweaks can make you look a LOT more involved without risking being annoying. Nobody gets annoyed by students who quietly get work done and make everyone’s life easier by anticipating needs and meeting them.

This post is absolutely excellent and I'm saving it for the time when my rotations start. In subjective evals we hear a lot of platitudes like "be more proactive," "show interest and prioritize the patients," "be a team player" etc. but this post does a fantastic job of giving the concrete "how" behind these concepts.

Working hard is important no matter what you're doing. But it's similar to how many of us end up transitioning from undergrad to med school. Just because I studied passively by reading powerpoints and syllabi in undergrad and excelled, there was no way I could do that in med school. I had to adjust by seeing my deficiencies and in my case, implementing more active learning methods like flashcards, visual mnemonics and practice questions before my med school performance approached that of undergrad. I think preclinical --> clinical rotations is a similar transition, and just working hard isn't enough; you have to learn to work differently to match the new situation. Keep your head up OP, after seeing the advice given here I think you just need to learn how to adapt your work style on rotations now that the subjective element is introduced, but if you can do that your grades will more likely reflect your book smarts and your hard work ethic.

 

[NeuResurgens]

For what it's worth, it goes both ways. The best residents are the ones who remain aware that med students are there to learn, should be given responsibility and not ignored, and also cognizant of the fact that they have shelf exams to take. I always did high-yield session with my students that was geared towards their shelves, and dismissed them early most days - as soon as it was clear nothing was going on. I also try to tailor the rotation to their specialty of interest, I can usually find some pearls or some things that will be relevant to their field. Too many residents get overwhelmed and don't make an effort to teach or forget what it's like to be a medical student.

Tangentially related to the OP, but I have a question related to the bolded part. I've heard students should stick around as long as is needed to help the team flow well, get work done etc. and sometimes residents or attendings will tell them they can go home before that. Some give advice not to duck out as soon as someone says you can go, but to stick around past that time and keep actively helping. Any advice on when you really should leave vs. when might be a good time to stay, even though your residents and attendings say you can go? Trying to find the right balance between helping the team as much as possible and also having good study time for rotation material outside the clinic.

 

[UnoMas]

I showed up 10-15 minutes earlier than my interns/residents, pre-rounded on all my assigned patients, wrote notes even though I was told they are optional, befriended and talked to the nurses on the floors, volunteered to do stuff to help out with the team, nothing was beneath me: faxing stuff, calling outside pharmacy, tracking down family members, social workers etc. things that are annoying to my interns and residents. In return, they helped me tailor my presentations to each individual attending, gave me great feedback, let me in on procedures, buttered me up with the attending, sent me home at 3 pm on Fridays. I got great evals and LORs for my effort. I even became friends with a few residents and they hooked with up with their friends/attendings in my specialty of interest. Never once I had to fake an interest in their specialties, I was usually asked early on what I wanted to do and I told them the truth but I also told them that I wanted to learn everything they can teach me during my rotation because I will be a physician first, specialist second. I mean you are a medical student, I don't think you know enough to know which opportunity is educational and which isn't. Everything you do will be noticed and I think will come back to reward you in its own way. It truly is a game and it isn't too hard to play. Scuts are scuts, do them, it's only for a few weeks.

Also remember if you are doing all your rotations in 1 hospital, it's always nice to walk with your new team and run into your old team on the floors and your old attending says to your new attending 'oh you have UnoMas this month, he/she's a great student.'

 

[Snoopy2006]

Tangentially related to the OP, but I have a question related to the bolded part. I've heard students should stick around as long as is needed to help the team flow well, get work done etc. and sometimes residents or attendings will tell them they can go home before that. Some give advice not to duck out as soon as someone says you can go, but to stick around past that time and keep actively helping. Any advice on when you really should leave vs. when might be a good time to stay, even though your residents and attendings say you can go? Trying to find the right balance between helping the team as much as possible and also having good study time for rotation material outside the clinic.

Honestly if a resident or attending tells a student they can go, and later knocks them on their eval for not sticking around, they're a tool. I'm not saying it can't happen, but I'd like to think that's the rare exception to the rule.

I dismiss my students because I try to stay cognizant of the time they need to be students outside of the wards. I'd like to think most people are doing the same. If someone tells you you can go, it's not a trap.

If there's something specific going on that you'd like to stick around for (e.g. a certain procedure) then you can explain you'd like to stick around, but if you're clearly dismissed, you're clear to go.

 

[IMreshopeful]

were clearly talking about different things and its my fault for the misunderstanding. I am not talking about patient care. I am specifically talking about minimally educational experiences like sending labs when the resident has little else to do and the student can easily be studying. and again, I understand its a team effort, but no resident should look down upon a student who doesn't volunteer to do scut work and is instead using that time to read up on their patients, etc. I have been in this situation before, when I was clearly using my time productively to learn and I was given menial tasks to do instead. I think I have a right to question the value of my education at that point. of course I always do the task for whoever asks me anyway. I am a joy to work with because I'm not a brown-noser and most of the residents Ive worked with appreciate that. ill offer to help them because I know it makes their life easier, not because I think thats what I should be doing. if I don't like them, however, I will ignore them entirely. if you're not interested in my education then **** off and I'm gonna do me. thats not being entitled.

maybe youre that resident that thinks a student should be sitting around at 3 PM when there is almost nothing else to do when you could send the student home to study and handle their business (the residents that do this realize that its not the students job to be sitting around, its theirs). I seem to jive well with those residents, not the anal ones who tell me I should be a brown-noser (i have literally heard this from one of my residents).

You literally misunderstood everything I said

1. I do not expect my medical students to "sit around" at 3 PM when they could go home and study. I don't actually have medical students a whole ton on my services anymore as a fellow, but when I did, I would make sure they were engaged with the service. My interns (especially later in the year) were *usually* mostly done with notes and would spend most of their time primarily either doing required procedures (paracentesis, thora, etc), helping to dispo patients, or admitting if it's a call day. Any number of these are things medical students can help with. In general, if there truly is nothing going on by the early afternoon, I do send my students home; however, on a call day where they (and the whole team) are expected to be there until 9 PM, I make sure that each medical student does at LEAST one new admission and is ready to present it the next day before they leave the hospital, in addition to dealing with their own patients already on service. If the census is heavy and service is busy, I don't keep the students there late, but I don't expect them to leave at 2 PM to go sit in a library either.

2. I'm curious what your definition of "scutwork" is. Third year is not just going to rotations to present a patient and go off and study. Your job is to learn not just the science of medicine but the WORK of medicine. When you become a resident - irrespective of whatever field you are in (maybe other than pathology), you will have to do at least a year of residency where you are doing clinical work in an inpatient setting. You need to know how to recognize sick and not sick (something that's a basic intern skill), learn how to deal with tough situations (dying patient, family meeting to discuss goals of care, managing angry patients and family members, dealing with grief), learn how physicians interact with each other on service and with their patients (and learn how NOT to interact with people, for that matter). Not all of this requires you to be doing something "worthy" of your time - it could just mean observing a procedure, sitting in on a family meeting without speaking about a patient of yours (though I frequently involved my medical students, who often knew the family better than me!), helping with minor things to tee up dispo, etc. Sorry to say that medicine isn't a sexy profession in any specialty - there's plenty of gruntwork that needs to be done, what you refer to as "menial tasks". Yes, I get that you need to study - you can always find time. I would be in surgeries all day on my surgical rotation in addition to waking up early, coming home late, and STILL had to use my weekends and any free time between cases to open up my books. It doesn't excuse you from working hard on the service.

3. It doesn't generally take that much for me to give my students good evaluations. They don't need to be geniuses - if the students are intelligent and have a good fund of knowledge, that's a bonus, but it's not expected that you will have the knowledge base of a senior resident or fellow. Your grades come primarily from showing interest, being engaged, being helpful, and taking ownership of your patients in addition to how the attendings assess you using your presentations. In fact, I would say it's even more important, since the attendings usually ask the residents what they think of the students when providing evaluations!

4. Being a brown noser is NOT an attractive quality - in fact, it's usually easy for a resident to spot, and it's usually nauseating. Showing genuine interest is very easy to note. No, you don't have to love a specialty, but you do need to show an interest without going overboard. It's an art that you need to refine.

 

[IMreshopeful]

Honestly if a resident or attending tells a student they can go, and later knocks them on their eval for not sticking around, they're a tool. I'm not saying it can't happen, but I'd like to think that's the rare exception to the rule.

I dismiss my students because I try to stay cognizant of the time they need to be students outside of the wards. I'd like to think most people are doing the same. If someone tells you you can go, it's not a trap.

If there's something specific going on that you'd like to stick around for (e.g. a certain procedure) then you can explain you'd like to stick around, but if you're clearly dismissed, you're clear to go.

I think it's definitely the exception more than the rule - if your resident says "you can go", it means one of a few things: (1) the residents and interns are now just trying to get through the day and don't have the energy to teach because they're on call/post call and feel bad (2) the residents recognize that there's nothing left the students can help out with and want them to go home to study. At least for me, it NEVER meant "that actually is code for stay here".

 

[operaman]

Tangentially related to the OP, but I have a question related to the bolded part. I've heard students should stick around as long as is needed to help the team flow well, get work done etc. and sometimes residents or attendings will tell them they can go home before that. Some give advice not to duck out as soon as someone says you can go, but to stick around past that time and keep actively helping. Any advice on when you really should leave vs. when might be a good time to stay, even though your residents and attendings say you can go? Trying to find the right balance between helping the team as much as possible and also having good study time for rotation material outside the clinic.

Personally I dismiss students when the only thing left for me to do is administrative/charting stuff they can’t possibly help with. Sometimes I’ll even follow it with telling them it’s not a test and that I’ll dock their grade if they DON’T gtfo. Sometimes for holiday weekends I’ve told students to stay home and told them I will personally blackball then if they try to come in, just so there’s absolutely no confusion. I remember residents on my sub-i doing this for me and the absence of ambiguity was much appreciated.

If you’re taking notes with the interns and following up all the day’s tasks, you’ll know without asking if all the work is done. If it is, ask what else needs to be done and double check with the more junior folks as well. Students may ask me and I may not have any work left, but the intern may need a hand with something so check in before leaving. I make a point to try and have our whole team leave the hospital at the same time after we’ve ensured there’s absolutely no remaining work left to do.

 

[NeuResurgens]

Honestly if a resident or attending tells a student they can go, and later knocks them on their eval for not sticking around, they're a tool. I'm not saying it can't happen, but I'd like to think that's the rare exception to the rule.

I dismiss my students because I try to stay cognizant of the time they need to be students outside of the wards. I'd like to think most people are doing the same. If someone tells you you can go, it's not a trap.

If there's something specific going on that you'd like to stick around for (e.g. a certain procedure) then you can explain you'd like to stick around, but if you're clearly dismissed, you're clear to go.

Personally I dismiss students when the only thing left for me to do is administrative/charting stuff they can’t possibly help with. Sometimes I’ll even follow it with telling them it’s not a test and that I’ll dock their grade if they DON’T gtfo. Sometimes for holiday weekends I’ve told students to stay home and told them I will personally blackball then if they try to come in, just so there’s absolutely no confusion. I remember residents on my sub-i doing this for me and the absence of ambiguity was much appreciated.

If you’re taking notes with the interns and following up all the day’s tasks, you’ll know without asking if all the work is done. If it is, ask what else needs to be done and double check with the more junior folks as well. Students may ask me and I may not have any work left, but the intern may need a hand with something so check in before leaving. I make a point to try and have our whole team leave the hospital at the same time after we’ve ensured there’s absolutely no remaining work left to do.

Great advice, thanks for the help!