Medicine first. Tips? (not pros/cons)

[seminoma]

Pretty sure I want to do something surgical and I chose to do medicine as my first rotation because I felt like for me the benefits outweighed the risks.

Got our official assignments yesterday and now that I'm locked in I am hoping you all could give me some advice about ways to be successful (actually learning, shelf, evals) when doing medicine, in particular, first.

What kinds of things should I really focus on learning because they won't be "taught" as much on other rotations? Is that even a reasonable thing to ask?

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[redpanda]

Pretty sure I want to do something surgical and I chose to do medicine as my first rotation because I felt like for me the benefits outweighed the risks.

Got our official assignments yesterday and now that I'm locked in I am hoping you all could give me some advice about ways to be successful (actually learning, shelf, evals) when doing medicine, in particular, first.

What kinds of things should I really focus on learning because they won't be "taught" as much on other rotations? Is that even a reasonable thing to ask?

1. Read about your patients. At least one topic/per patient/per day. Combination of a review book plus some UptoDate. Ex. Pt A admitted with ab pain: read about differential dx and how to sort it out. HD1 - looks like pt has pancreatitis: read about treatment of pancreatitis. HD2 - read about natural history and prognosis and complications of pancreatitis, etc. Even your admissions which are for ostensibly "social" reasons (aka active problems not really being managed differently in-hospital) can contain topics to read about (i.e. management of hypertension in the inpatient setting).
2. Read some review book for bread and butter things. Many different books available. I used Step Up to Medicine and did more of this general sort of reading in the second half of my inpatient ward rotation. You should cover the entire book by the end of the rotation.
3. Figure out what your team members want from your presentation. Bedside daily rounds presentation is entirely different from new admission presentation to your attending in her office. Ask your resident who can tell you what he/she wants on rounds versus what the deets about each attending are.
4. Make sure your presentations at the bedside are succinct. 5 min or less with a minimal use of notes. Keeping it short means that most of it can be from memory with maybe a look at the notes for lab values. Neither your team nor your patient wants to sit through a 15 min discourse on...whatever.
5. If you come across a piece of new primary literature in the course of your UptoDate reading about patients and it seems pretty relevant to your patient, include this in the plan part of your presentation (if relevant). You will look like a superstar (but certainly not required).
6. Do not get behind in reading. You have a massive quantity to learn for the shelf. It's easier to swallow over 8 weeks than 3 weeks, or gods forbid, 3 days.
7. Help your intern with whatever scut that it is possible for you to help with. Does your attending expect you to update a family member each day if the patient wants it and this person is not bedside? Make those calls. Does the patient not know WTF they're taking for meds? Scour the chart, call the PCP, or even better, call their pharmacy to see what was filled recently. Call consults if your intern is comfortable with that.

 

[TraumaLlamaMD]

Medicine is your chance to see the inpatient treatment of common and uncommon problems you will encounter in every specialty. It's probably the best place to get comfortable with the presentation and management of issues like CHF, COPD exacerbations, liver disease, etc - issues which will still be present when you're on your surgical rotations. Your subsequent rotations will likely be more focused on a specific body system or on outpatient medicine, so this may be the time when you are most likely to view your patient from a complete, zoomed-out perspective.

Your surgical rotations may focus more on anatomy and pre/post op management, but many of your patients will have underlying medical issues as well. Knowing in advance how these are managed will give you an advantage in coming up with a comprehensive plan for your future patients - one that doesn't have to include "consult medicine."

It's also a good opportunity to practice assessing a new patient, writing a complete but concise H&P, presenting a patient on rounds (although the speed of rounds and emphasis on certain parameters will vary between medicine and surgery - I am still grateful I did medicine before surgery because there was just no way I could go back to the pace of medicine rounds after my surgical rotations!) and starting to gain confidence in your physical exam and patient interaction skills.

 

[seminoma]

@redpanda, @TraumaLlamaMD

Super helpful, thank you so much!

Is there a pocket book that is recommended to carry around to study during any potential downtime? Any pocket book that is recommended for quick reference for patient care?

 

[redpanda]

@redpanda, @TraumaLlamaMD

Super helpful, thank you so much!

Is there a pocket book that is recommended to carry around to study during any potential downtime? Any pocket book that is recommended for quick reference for patient care?

If there was "downtime", I was reading UptoDate on the computer. There's no need to be carrying around a pocket book if there are enough computers around. That being said, there was very little downtime for us as medical students. Pre-rounding, rounding, daily education time, writing notes, and new admissions usually ate up the day.

 

[TraumaLlamaMD]

On my medicine clerkship I was encouraged to accompany my patients to procedures which I wouldn't otherwise necessarily have seen - biopsies, cath lab, stuff like that. I went down to pathology and the micro lab and asked if anyone had time to go over my patient's slides with me, which has the added benefit often of getting results faster. Definitely take advantage of this if you're allowed (it was mentioned in my eval as me taking an extra step of ownership for and interest in my patients, actually).

 

[cabinbuilder]

@redpanda, @TraumaLlamaMD

Super helpful, thank you so much!

Is there a pocket book that is recommended to carry around to study during any potential downtime? Any pocket book that is recommended for quick reference for patient care?

Pocket Medicine by Marc S. Sabatine
Practical guide to the care of the medical patient by Ferri.

 

[image187]

1. Do half of UW medicine questions
2. read "step-up" if you can
3. quick look up something new for 5 mins every day,
4. chill often
5. don't gun

 

[clausewitz2]

I would actually suggest having a hard copy review book close to hand for downtime because that way no one thinks you are goofing off and Facebooking when things are at a lull.

 

[seminoma]

I would actually suggest having a hard copy review book close to hand for downtime because that way no one thinks you are goofing off and Facebooking when things are at a lull.

So.. just carry a book around all day?

 

[clausewitz2]

Certainly what I did. Or stash one in the resident workroom (if you have downtime, it is generally not because you are out walking the floor right at that moment). Patient visitor walking by might swipe your ipad or phone, they are probably not that keen on swiping Casefiles or Step Up to Medicine. I attribute getting good evals on one particularly slow rotation to the fact that after I finished my notes I could crack open an obvious book and be seen as studious, rather than illuminating my face with a phone screen and casting hopeful "Can I go yet?" glances towards my residents.

 

[redpanda]

I would actually suggest having a hard copy review book close to hand for downtime because that way no one thinks you are goofing off and Facebooking when things are at a lull.

In the workrooms we have, it's going to be pretty darn obvious if you were on fb (if it weren't blocked). Nobody would think you were doing things un-academic on the computer unless you, you know, actually were seen on the site. Frankly, I didn't need to stuff my coat or bag with yet another thing to carry around. It gets heavy!

 

[Dave89]

I would actually suggest having a hard copy review book close to hand for downtime because that way no one thinks you are goofing off and Facebooking when things are at a lull.

It's 2015. I think that most attendings and residents are now aware that many study resources can be accessed on one's phone.

Unless reading BRS or doing UWorld puts OP in a suspiciously humorous mood, (s)he will be fine.

 

[clausewitz2]

In the workrooms we have, it's going to be pretty darn obvious if you were on fb (if it weren't blocked). Nobody would think you were doing things un-academic on the computer unless you, you know, actually were seen on the site. Frankly, I didn't need to stuff my coat or bag with yet another thing to carry around. It gets heavy!

I am really talking about phones rather than desktops. Those, obviously everyone can see what you are doing, but you may not always have access to one in a particularly crowded workroom (definitely the case on BMT for me with a bunch of residents, three pharmacists, a fellow...)

 

[clausewitz2]

It's 2015. I think that most attendings and residents are now aware that many study resources can be accessed on one's phone.

Unless reading BRS or doing UWorld puts OP in a suspiciously humorous mood, (s)he will be fine.

I am sure if you asked them straight up they would agree that there are totally resources you can access that way. I however suspect the bias is not operating at a conscious, explicit level.

 

[seminoma]

I am really talking about phones rather than desktops. Those, obviously everyone can see what you are doing, but you may not always have access to one in a particularly crowded workroom (definitely the case on BMT for me with a bunch of residents, three pharmacists, a fellow...)

This has been a concern of mine in regard to people thinking you're messing around.

 

[redpanda]

This has been a concern of mine in regard to people thinking you're messing around.

Well, looking like you're on task and actually having a good fund of knowledge tend to dispel any perceptions that people think you're messing around. Do your reading religiously and don't act like you don't want to be there.

 

[TraumaLlamaMD]

I had the Uworld app on my phone and my medicine residents at one location were really excited to test themselves with my step 2 practice questions... Go figure, I wouldn't mind if I never saw Uworld again!

 

[addy]

1. Do half of UW medicine questions
2. read "step-up" if you can
3. quick look up something new for 5 mins every day,
4. chill often
5. don't gun

Do people actually honor w just UW questions? I read the "official" thread for the IM shelf and everyone keeps saying you should do UWorld, MKSAP, Step up, case file, etc etc. I don't know how they get through all of that in 2 months...

 

[massmocha]

Pretty sure I want to do something surgical and I chose to do medicine as my first rotation because I felt like for me the benefits outweighed the risks.

Got our official assignments yesterday and now that I'm locked in I am hoping you all could give me some advice about ways to be successful (actually learning, shelf, evals) when doing medicine, in particular, first.

What kinds of things should I really focus on learning because they won't be "taught" as much on other rotations? Is that even a reasonable thing to ask?

I think this is the best order (Medicine before Surgery). Just follow all your patients closely, read the UpToDate article about their condition, be interested and enthusiastic, show up early, don't ask to leave, write good notes, do 100 Step 2CK UWorld questions each night.

Having medicine behind you will help you a lot when you get to the surgery shelf and have the background knowledge.

Good luck!

 

[massmocha]

Do people actually honor w just UW questions? I read the "official" thread for the IM shelf and everyone keeps saying you should do UWorld, MKSAP, Step up, case file, etc etc. I don't know how they get through all of that in 2 months...

I honored Medicine using just UWorld questions for prep. I read 5 pages of step up to medicine and never opened it again

 

[redpanda]

Do people actually honor w just UW questions? I read the "official" thread for the IM shelf and everyone keeps saying you should do UWorld, MKSAP, Step up, case file, etc etc. I don't know how they get through all of that in 2 months...

I don't know what everyone else did, but I got honors, including a really great shelf score, using a combination of the above. Did a good chunk (50-60% maybe) of the UWorld IM questions during that block, read all of Step Up, and then did a little reading in MKSAP and Case Files. That being said, a good chunk of the knowledge acquisition for that shelf happened before the rotation (i.e. learning preclinical material very well and studying a lot in previous 2 rotations, which included family medicine). You can't learn all the medicine material in whatever the stretch of your IM rotation is. It's really a yearlong process.

 

[seminoma]

When you guys mention UW are you talking about UW for ABIM? Or for Step 2?

 

[massmocha]

When you guys mention UW are you talking about UW for ABIM? Or for Step 2?

Step 2 CK UWorld

 

[mcloaf]

Is this the MKSAP we're talking about here? Man that's ****ing expensive.

Edit: nevermind, looks like MKSAP5 is the one people mean, phew.

 

[seminoma]

Step 2 CK UWorld

So basically everyone pays for 12 months of UW?

 

[massmocha]

So basically everyone pays for 12 months of UW?

At my school it is paid for by the medicine department. I guess that's the deal if your school doesn't cover it

 

[seminoma]

At my school it is paid for by the medicine department. I guess that's the deal if your school doesn't cover it

My school made us pay for the mandatory cpr class so I doubt they're covering UW for us haha.

Thanks for your help

 

[massmocha]

My school made us pay for the mandatory cpr class so I doubt they're covering UW for us haha.

Thanks for your help

Yikes... yeah I didn't know how common that was, but I definitely wasn't about to question a free QBank

 

[DrYoda]

What kinds of things should I really focus on learning because they won't be "taught" as much on other rotations? Is that even a reasonable thing to ask?

This is IMO one of the bigger causes of issues with students moving from the preclinical to clinical years. Don't expect to be taught. If you have a teaching heavy attending that's great and a good learning opportunity, but also don't expect what the cardiology attending teaches to necessarily be a big part of the shelf exam. By this point I hope you know your own learning style pick up step-up to medicine, UW or whatever tool you think most compliments your way of learning and hit it hard.

 

[seminoma]

This is IMO one of the bigger causes of issues with students moving from the preclinical to clinical years. Don't expect to be taught. If you have a teaching heavy attending that's great and a good learning opportunity, but also don't expect what the cardiology attending teaches to necessarily be a big part of the shelf exam. By this point I hope you know your own learning style pick up step-up to medicine, UW or whatever tool you think most compliments your way of learning and hit it hard.

Sorry if I wasn't clear. I was referring to things that aren't necessarily found in books, but are clerkship/specialty specific. An example would be that outside of surgery/OB/EM there probably won't be many opportunities to learn to suture. Was asking if medicine has it's own special things that every M3 should come out of knowing (because they might not get another good chance).

My point of view is that it's my job to seek out opportunities to learn what I can and also what I need to learn rather than just showing up everyday and waiting for the teaching/learning to come my way. So I kind of just want to know if there's anything I absolutely need to pursue in the event that it isn't readily available.

 

[WinslowPringle]

Medicine in specific:
1. Master the presentation. Good subjective, nice flow into vitals, exam, I/Os, labs, and then have a solid 1-2 sentence summary before you present a plan. Keep it professional - no vocal fry, minimal fillers, no uptalk (unless you are actually asking a question). Look confident, not cocky. Practice at home, recorded, if you have to. A good presentation is key; it makes one look more knowledgeable than one actually may be. Don't just read off your sheet. Actually try to develop a plan by yourself - great for learning. Medicine is really great for this and here the attendings really care about it; you can always trim it down on surgery.
2. Agree with the above - keep a book on you. The Pocket Medicine is super handy (for IM, FM, EM, and GS even...). I personally love the Washington Subspecialty Consult in Nephrology - great explanations for acid base and electrolyte disturbances.
3. Really work on your fluid/electrolyte management and the reasons why. Important for medicine and surgery.
4. Read as many EKGs as you can.
5. Review medication indications, mechanisms of action, and effects. You'll see them over and over again and they're more memorable in a clinical context, when working with your patient; medicine is great for this. High-yield (not for Boards, but personal use) meds are for cardiac and renal disease, pain meds, and antibiotics.
6. The basic things that M3s should know are reflected in the shelf: basic differentials, workups, treatment for cardiac, renal, hepatic, GI, infectious, pulmonary disease, etc. Yeah, pretty much everything

Rotations in general:
1. Keep an open mind in terms of what you like/don't like in specialties.
2. Develop a data-gathering system. Personally, I saw the patients first. Then chart-reviewed: vitals, I/Os, labs, med admin record, orders. Then wrote my note.
3. Develop a tracking system. I like blank sheets of paper that I can quarter up and follow a single patient for 16 days. Some people like fancy sheets with lines drawn for all the labs. Note cards for some. Rounding reports for others. Find what works. Also great on medicine because there is more to keep track of.
4. Find the people who are great at teaching - and let them teach. Ask them questions. Ask why. Know when and whom to question and when and whom not to question.

 

[seminoma]

What's uptalk?

 

[WinslowPringle]

What's uptalk?

It's like ? You're asking a questiiion? But you're really not?

Vocal uprising at the end of a sentence, which in English usually indicates a question. It makes one sound unsure and insecure.

 

[Kaustikos]

It's like ? You're asking a questiiion? But you're really not?

Vocal uprising at the end of a sentence, which in English usually indicates a question. It makes one sound unsure and insecure.

Also never lie
Also never say "I didn't have the time to fully examine/see the patient."

 

[abolt18]

What's uptalk?

I don't know, what's up with you?

 

[abolt18]

Medicine in specific:
1. Master the presentation. Good subjective, nice flow into vitals, exam, I/Os, labs, and then have a solid 1-2 sentence summary before you present a plan. Keep it professional - no vocal fry, minimal fillers, no uptalk (unless you are actually asking a question). Look confident, not cocky. Practice at home, recorded, if you have to. A good presentation is key; it makes one look more knowledgeable than one actually may be. Don't just read off your sheet. Actually try to develop a plan by yourself - great for learning. Medicine is really great for this and here the attendings really care about it; you can always trim it down on surgery.
2. Agree with the above - keep a book on you. The Pocket Medicine is super handy (for IM, FM, EM, and GS even...). I personally love the Washington Subspecialty Consult in Nephrology - great explanations for acid base and electrolyte disturbances.
3. Really work on your fluid/electrolyte management and the reasons why. Important for medicine and surgery.
4. Read as many EKGs as you can.
5. Review medication indications, mechanisms of action, and effects. You'll see them over and over again and they're more memorable in a clinical context, when working with your patient; medicine is great for this. High-yield (not for Boards, but personal use) meds are for cardiac and renal disease, pain meds, and antibiotics.
6. The basic things that M3s should know are reflected in the shelf: basic differentials, workups, treatment for cardiac, renal, hepatic, GI, infectious, pulmonary disease, etc. Yeah, pretty much everything

Rotations in general:
1. Keep an open mind in terms of what you like/don't like in specialties.
2. Develop a data-gathering system. Personally, I saw the patients first. Then chart-reviewed: vitals, I/Os, labs, med admin record, orders. Then wrote my note.
3. Develop a tracking system. I like blank sheets of paper that I can quarter up and follow a single patient for 16 days. Some people like fancy sheets with lines drawn for all the labs. Note cards for some. Rounding reports for others. Find what works. Also great on medicine because there is more to keep track of.
4. Find the people who are great at teaching - and let them teach. Ask them questions. Ask why. Know when and whom to question and when and whom not to question.

Thanks for this.

 

[seminoma]

This is more of a general MS3 question, but is there any benefit to buying one of those white coat clipboard things? Does it really make your life easier? I think a lot of people in my class are going to buy one so I don't want to look like I'm unprepared for not having one... but I also don't want to look like another MS3 following the herd and using an unnecessary shortcut/tool you know?

Also is it ever a good idea to ask to see more patients if you feel like your workload is light? Would it make a good impression (assuming you do a good job) or would you just look like a gunner? I've been told by some older students that they only had to follow 1 patient at any given time, whereas at other schools I know MS3 are expected to follow 2-3+ patients. So I imagine 2-3 is a reasonable amount of work for an MS3 and obviously 2-3 patients means more learning than 1 patient.

@TraumaLlamaMD
@redpanda
@cabinbuilder
@clausewitz2
@image187
@Dave89
@massmocha
@DrYoda
@WinslowPringle
@Kaustikos

 

[Dave89]

This is more of a general MS3 question, but is there any benefit to buying one of those white coat clipboard things? Does it really make your life easier?

Yes. Keeps papers in order and makes taking notes much easier.

 

[Psai]

It's like ? You're asking a questiiion? But you're really not?

Vocal uprising at the end of a sentence, which in English usually indicates a question. It makes one sound unsure and insecure.

omg i do this all the time
i'm not confident in my answers even though I'm right a decent amount of the time. it's a hard habit to break

 

[Mr. Mojo Risin]

Can anybody comment on scutsheets like these, or are most of you here just writing on some blank paper? I've asked a few of my friends on rotations now and some of them use round reports. I'm just curious to hear what different methods students use to keep organized so I can play around with a few and see what works best for me.

 

[Psai]

I just write on the sign out sheets

 

[WinslowPringle]

This is more of a general MS3 question, but is there any benefit to buying one of those white coat clipboard things? ...

Also is it ever a good idea to ask to see more patients if you feel like your workload is light? ...

Among my classmates, I'd say about 1/3 that got the clipboards loved them, 1/3 liked them ok but didn't always use them, and 1/3 got them and didn't really use them. [I didn't use one- too big and too much writing space.]

For patients, it will depend on the rotation: the resident preferences, number of students, and what 'following a patient' means at your place (writing all orders that are pended? Just notes? Lots of dressing changes?). Around here, 2-3 patients was normal at beginning of M3. Talk with your team about expectations; asking politely to follow another patient is generally fine. The answer may be no, of course, which is also fine - there can be plenty to learn even with only one patient.

 

[Kaustikos]

omg i do this all the time
i'm not confident in my answers even though I'm right a decent amount of the time. it's a hard habit to break

Surgery was the worst place to use that. I had to force myself to answer in the affirmative. Or be mocked with statements like "This isn't jeopardy. Stop answering with a question"