Medicine rotation

[mdhopeful99]

M3 currently on medicine. Wondering people's advice for making the most out of short time with attendings during rounds each day, outside of the obvious. I've been on top of my patient presentations and formulate solid A/Ps according to my resident team. I'm trying to take on as many patients as I can (within reason), I'm calling consults, placing orders, writing progress notes and discharge summaries, setting up post-hospitalization appts - my resident team is aware of these things, but the attending likely doesn't know aside from if they happen to see my name at the bottom of the notes and stuff like that. My attending changes on a weekly basis. Understandably they are very busy, rounds tend to be fast paced and even with doing well on rounds I am stuck wondering if I'm making enough of an impression. Some days will be phone rounds, I doubt my attending even remembers my name with such limited interaction, so I don't think they'll know my voice or take the time to pay close enough attention to which med student is presenting over the phone. There have even been a few occasions where rounds didn't happen at all. I've asked to do a brief presentation after rounds on an interesting topic going on with a patient at times and felt that was well received and successful, but I want to be careful with doing that (don't want to over do it, don't want to add to an already busy attendings schedule/time on rounds). In addition to senior residents, the attendings will be writing my evals, anyone have advice for how to continue making good impressions or how to go above and beyond with such limited in person time with attendings?

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[eteshoe]

Most likely if you're making a solid impression on your team (as it seems you are), the attendings tend to consult the senior residents to get more information about you when they're evaluating you. The constant turnover is a quirk of the rotation system but since you're on the same team for a few wks, the residents usually can speak to your evolution, skills, and profile as a trainee (which they convey to the attendings).

 

[ChordaEpiphany]

The constant turnover is a quirk of the rotation system but since you're on the same team for a few wks, the residents usually can speak to your evolution, skills, and profile as a trainee (which they convey to the attendings).

I'm also struggling with this, but with much more turnover and even more transient interactions with attendings. On both peds and obgyn we changed teams and attendings daily. Even now on medicine we change services weekly. It's an absolutely brutal and mind-numbing experience in which you learn nothing about the specialty and spend 90% of your time trying to figure out EPIC templates or where to find your patient. You wake up every day anxious because most of the time no one from the team communicated with you at all, and you're just praying you can get to the right room semi-prepared for the day. You also get zero chance to improve. Half the time presentations wind up with the attending criticizing you for something another attending told you to do, and now you can't even show you can learn (e.g., "In summary, Patient X is a 45 yo male w/ a pmh of Y with symptoms most consistent with Z, supported by A, B, and C. We can also consider diagnosis D, but it is less likely-" "Just tell us your plan." Then the next day on rounds with another attending, "... supported by A, B, and C. For problem Z, I would like to-" "You haven't given us any pertinent negatives. I expect at least 3 items on your DDx."). Then you never see the attending again.

Then of course attendings give mediocre evals. On those rotations, honoring becomes entirely about knowing who to send evals to and who to pretend you never worked with. Also, it seems unlikely attendings are really meeting with residents to see who the great students are. Our evals are only filled out half the time, and usually they're a couple sentences with the equivalent of "read more." I've only been able to scrape out honors by essentially reading people right and sending evals or getting lucky with site placement.

 

[Styrene]

M3 currently on medicine. Wondering people's advice for making the most out of short time with attendings during rounds each day, outside of the obvious. I've been on top of my patient presentations and formulate solid A/Ps according to my resident team. I'm trying to take on as many patients as I can (within reason), I'm calling consults, placing orders, writing progress notes and discharge summaries, setting up post-hospitalization appts - my resident team is aware of these things, but the attending likely doesn't know aside from if they happen to see my name at the bottom of the notes and stuff like that. My attending changes on a weekly basis. Understandably they are very busy, rounds tend to be fast paced and even with doing well on rounds I am stuck wondering if I'm making enough of an impression. Some days will be phone rounds, I doubt my attending even remembers my name with such limited interaction, so I don't think they'll know my voice or take the time to pay close enough attention to which med student is presenting over the phone. There have even been a few occasions where rounds didn't happen at all. I've asked to do a brief presentation after rounds on an interesting topic going on with a patient at times and felt that was well received and successful, but I want to be careful with doing that (don't want to over do it, don't want to add to an already busy attendings schedule/time on rounds). In addition to senior residents, the attendings will be writing my evals, anyone have advice for how to continue making good impressions or how to go above and beyond with such limited in person time with attendings?

Schedule a feedback meeting if possible and bring up how you have been contributing to the team in the context of seeking any areas of improvement.

 

[jhmmd]

M3 currently on medicine. Wondering people's advice for making the most out of short time with attendings during rounds each day, outside of the obvious. I've been on top of my patient presentations and formulate solid A/Ps according to my resident team. I'm trying to take on as many patients as I can (within reason), I'm calling consults, placing orders, writing progress notes and discharge summaries, setting up post-hospitalization appts - my resident team is aware of these things, but the attending likely doesn't know aside from if they happen to see my name at the bottom of the notes and stuff like that. My attending changes on a weekly basis. Understandably they are very busy, rounds tend to be fast paced and even with doing well on rounds I am stuck wondering if I'm making enough of an impression. Some days will be phone rounds, I doubt my attending even remembers my name with such limited interaction, so I don't think they'll know my voice or take the time to pay close enough attention to which med student is presenting over the phone. There have even been a few occasions where rounds didn't happen at all. I've asked to do a brief presentation after rounds on an interesting topic going on with a patient at times and felt that was well received and successful, but I want to be careful with doing that (don't want to over do it, don't want to add to an already busy attendings schedule/time on rounds). In addition to senior residents, the attendings will be writing my evals, anyone have advice for how to continue making good impressions or how to go above and beyond with such limited in person time with attendings?

What exactly is your question?

 

[coffegroundemesis]

M3 currently on medicine. Wondering people's advice for making the most out of short time with attendings during rounds each day, outside of the obvious. I've been on top of my patient presentations and formulate solid A/Ps according to my resident team. I'm trying to take on as many patients as I can (within reason), I'm calling consults, placing orders, writing progress notes and discharge summaries, setting up post-hospitalization appts - my resident team is aware of these things, but the attending likely doesn't know aside from if they happen to see my name at the bottom of the notes and stuff like that. My attending changes on a weekly basis. Understandably they are very busy, rounds tend to be fast paced and even with doing well on rounds I am stuck wondering if I'm making enough of an impression. Some days will be phone rounds, I doubt my attending even remembers my name with such limited interaction, so I don't think they'll know my voice or take the time to pay close enough attention to which med student is presenting over the phone. There have even been a few occasions where rounds didn't happen at all. I've asked to do a brief presentation after rounds on an interesting topic going on with a patient at times and felt that was well received and successful, but I want to be careful with doing that (don't want to over do it, don't want to add to an already busy attendings schedule/time on rounds). In addition to senior residents, the attendings will be writing my evals, anyone have advice for how to continue making good impressions or how to go above and beyond with such limited in person time with attendings?

I am glad I go to a pass fail school (t5). Your anxiety level is insane. At my school, I had at most 2 patients at a time. Didn’t kiss anyone’s ass. Wrote a note or two every other day. Didn’t need to do a d/c summary or make post hospitalization follow up appointments. Passed and the school only put in the super positive comments in the course eval.

 

[jhmmd]

I am glad I go to a pass fail school (t5). Your anxiety level is insane. At my school, I had at most 2 patients at a time. Didn’t kiss anyone’s ass. Wrote a note or two every other day. Didn’t need to do a d/c summary or make post hospitalization follow up appointments. Passed and the school only put in the super positive comments in the course eval.

P = MD

 

[Kierkegaard's Bud]

I am glad I go to a pass fail school (t5). Your anxiety level is insane. At my school, I had at most 2 patients at a time. Didn’t kiss anyone’s ass. Wrote a note or two every other day. Didn’t need to do a d/c summary or make post hospitalization follow up appointments. Passed and the school only put in the super positive comments in the course eval.

Residency will welcome you with open arms.

 

[coffegroundemesis]

Residency will welcome you with open arms.

As a matter of fact, we match exceedingly well. Also I have decided to go to one of the home programs in medicine. Residency will be more hectic but the anxiety level is never high here because people don’t feel the need to impress anyone here. We are already at the top of the ranking, so there’s literally nothing to gain by gunning at this point.

 

[Kierkegaard's Bud]

As a matter of fact, we match exceedingly well. Also I have decided to go to one of the home programs in medicine. Residency will be more hectic but the anxiety level is never high here because people don’t feel the need to impress anyone here. We are already at the top of the ranking, so there’s literally nothing to gain by gunning at this point.

I’m talking about your clinical acumen, not matching. Only seeing 2 patients which you don’t even have to write notes on seems like the learning curve is going to be steep.

 

[mdhopeful99]

As a matter of fact, we match exceedingly well. Also I have decided to go to one of the home programs in medicine. Residency will be more hectic but the anxiety level is never high here because people don’t feel the need to impress anyone here. We are already at the top of the ranking, so there’s literally nothing to gain by gunning at this point.

I'm glad you go to a p/f T5 school too, and I'm glad your program matches exceedingly well - very cool! Not sure at what point work ethic equates to gunning, insane anxiety, and "kissing ass," but we're all entitled to our opinions on the matter. The fact is, the specialties I am considering are quite competitive and I am showing up each day to set myself up for success in the future, if you think that's being a gunner then so be it. I posted this thread for advice on how to do well on my medicine rotation, telling me what you didn't do at your p/f institution really doesn't provide anything constructive for me to work with, but I appreciate you weighing in on the matter!!

 

[coffegroundemesis]

I’m talking about your clinical acumen, not matching. Only seeing 2 patients which you don’t even have to write notes on seems like the learning curve is going to be steep.

Med students don’t really learn anything anywhere, including the very top schools. Everyone basically starts fresh at the intern year. Medicine is just something that time will eventually teach you. No point to constantly try to leave an amazing impression on people. The performative nature of clerkship is quite ineffective and detrimental to a healthy development of a physician identity. I don’t think medical acumen is an issue at all. If you pass step 1 and 2, you have enough medical acumen to see almost all the patients. If you specialize, you will learn your specialty later on. The traditional thinking that medical school has to be grueling is so outdated and unnecessary. OP needs to focus on themselves instead of constantly worrying about how others perceive them. It’s bad for their mental health and eventually bad for the patients OP will eventually treat.

 

[coffegroundemesis]

I'm glad you go to a p/f T5 school too, and I'm glad your program matches exceedingly well - very cool! Not sure at what point work ethic equates to gunning, insane anxiety, and "kissing ass," but we're all entitled to our opinions on the matter. The fact is, the specialties I am considering are quite competitive and I am showing up each day to set myself up for success in the future, if you think that's being a gunner then so be it. I posted this thread for advice on how to do well on my medicine rotation, telling me what you didn't do at your p/f institution really doesn't provide anything constructive for me to work with, but I appreciate you weighing in on the matter!!

You are actually gunning, believe it or not. It’s not your fault. It’s the system you are in. I think you should really focus on your own mental health instead of constantly worrying about your performance. Tbh, the habitual anxiety will ruin your life later on.

 

[Chromium Surfer]

I’m talking about your clinical acumen, not matching. Only seeing 2 patients which you don’t even have to write notes on seems like the learning curve is going to be steep.

You are actually gunning, believe it or not. It’s not your fault. It’s the system you are in. I think you should really focus on your own mental health instead of constantly worrying about your performance. Tbh, the habitual anxiety will ruin your life later on.

No dog in the fight. I think the fact that coffeground goes to a T5 gives them a level of privilege that most students dont in regards to being able to cultivate a healthy work/life balance without having to kill themselves to impress people. Even for other schools where the rotations are p/f if they are not top 5 the benefit is not as great.

Also for what its worth I believe I remember seeing that coffee ground got like a 270+ on step 2 so I think their clinical acumen is fine. It is funny how laid back they are despite crushing step 2.

 

[mdhopeful99]

You are actually gunning, believe it or not. It’s not your fault. It’s the system you are in. I think you should really focus on your own mental health instead of constantly worrying about your performance. Tbh, the habitual anxiety will ruin your life later on.

I appreciate the sentiment of what you are trying to convey and understand where you are coming from. With that being said, this isn't something that is all consuming or keeping me up at night in the slightest. This is a forum designed for advice for medical students, as such, my post is tailored to my experiences on rotations and rotations alone, there is no use detailing my life outside of medicine and my ability to balance pleasure with work, every med student (and adult) may struggle with this in some form or another in life, but I have not had much issue finding a balance that works well for me and allows me to enjoy the things I like to do in life while succeeding in school.

My performance evaluators will be evaluating my performance, naturally I am going to be aware of, and pay attention to, their impressions of me while I am on service. While I'm not insinuating this is what you're directly advising, to not be concerned with how my evaluators perceive me at an institution where my evaluations make up a significant portion of my grade on the clerkship would be silly. I know the question I posed/advice I seek is not something unique to me or my institution, its a dilemma many students face. Sure, we can sit here and say it's the result of the system I am a part of, but that system is not going to be changing while I'm a student. To jump to conclusions about my mental health as a whole and my future ability to care for patients is quite a leap. I recognize where you are coming from, and agree that constantly focusing on other's perception of myself can be deleterious, no argument there. But to assume that's what I'm doing because I want to make the best impression on people who will have the final say on my grade is reaching.

 

[eteshoe]

I'm also struggling with this, but with much more turnover and even more transient interactions with attendings. On both peds and obgyn we changed teams and attendings daily. Even now on medicine we change services weekly. It's an absolutely brutal and mind-numbing experience in which you learn nothing about the specialty and spend 90% of your time trying to figure out EPIC templates or where to find your patient. You wake up every day anxious because most of the time no one from the team communicated with you at all, and you're just praying you can get to the right room semi-prepared for the day. You also get zero chance to improve. Half the time presentations wind up with the attending criticizing you for something another attending told you to do, and now you can't even show you can learn (e.g., "In summary, Patient X is a 45 yo male w/ a pmh of Y with symptoms most consistent with Z, supported by A, B, and C. We can also consider diagnosis D, but it is less likely-" "Just tell us your plan." Then the next day on rounds with another attending, "... supported by A, B, and C. For problem Z, I would like to-" "You haven't given us any pertinent negatives. I expect at least 3 items on your DDx."). Then you never see the attending again.

Then of course attendings give mediocre evals. On those rotations, honoring becomes entirely about knowing who to send evals to and who to pretend you never worked with. Also, it seems unlikely attendings are really meeting with residents to see who the great students are. Our evals are only filled out half the time, and usually they're a couple sentences with the equivalent of "read more." I've only been able to scrape out honors by essentially reading people right and sending evals or getting lucky with site placement.

I definitely feel you on these points. For my ob/gyn rotation we had a similar setup - I found it to be mostly dumb as hell since you're being judged on snapshots and hoping someone down the line can vouch for your improvement. For my own mental health, I just focused on doing well in the things I could control and conceding that getting all honors was either not in the cards or just not worth killing myself over.

I'm looking for this 9-yr chapter of my life to be over and move onto the next pile of bs I gotta deal with lol.

 

[coffegroundemesis]

No dog in the fight. I think the fact that coffeground goes to a T5 gives them a level of privilege that most students dont in regards to being able to cultivate a healthy work/life balance without having to kill themselves to impress people. Even for other schools where the rotations are p/f if they are not top 5 the benefit is not as great.

Also for what its worth I believe I remember seeing that coffee ground got like a 270+ on step 2 so I think their clinical acumen is fine. It is funny how laid back they are despite crushing step 2.

Well, privilege is the right word. It saddens me to see how they put med students through the wringer. Most of us become so traumatized after 4 years of med school. That’s just not sustainable. I genuinely enjoy med school and I think I have learned as much as I need. I don’t feel burnt out or stressed. Going forward, I’d like to make younger generations feel the same way. Unfortunately this kind of chill environment is only limited to the top places at this point.

 

[Kierkegaard's Bud]

Med students don’t really learn anything anywhere, including the very top schools. Everyone basically starts fresh at the intern year. Medicine is just something that time will eventually teach you. No point to constantly try to leave an amazing impression on people. The performative nature of clerkship is quite ineffective and detrimental to a healthy development of a physician identity. I don’t think medical acumen is an issue at all. If you pass step 1 and 2, you have enough medical acumen to see almost all the patients. If you specialize, you will learn your specialty later on. The traditional thinking that medical school has to be grueling is so outdated and unnecessary. OP needs to focus on themselves instead of constantly worrying about how others perceive them. It’s bad for their mental health and eventually bad for the patients OP will eventually treat.

Nobody said gunning is even acceptable. It should be rooted out.

“Everyone basically starts fresh at the intern year.” This statement of yours implies that all interns are created equal which doesn’t correlate with reality.

Since we are talking about ranking, I go to a t5 as well.

 

[operaman]

Some of these posts remind me of the former T5 student we fired as a pgy2 who also had 99th percentile scores. He too had clearly blown off hard work and learning clinical medicine and just could not catch up and had the most terrible entitled attitude to boot. And I’ve seen the same pattern repeat in other programs and in other fields.

I think there is a certain level of knowledge and skill students need to have and it’s sad that education is not much of a priority even in top schools. Interns are not all created equal - not even all chiefs are equal. Some people are genuinely better than others and my experience has been that it’s correlated more with their innate intelligence and work ethic than anything else.

Sadly, intern quality coming out of T5 schools can be rather hit and miss. There are quite a few admits to these schools who get in because of a cool back story or to fill a quota and then get passed along and graduated with an MSPE that bends over backwards to obscure any indicator of how they compare to others.

Don’t get me wrong - lots of strong grads as well. It’s just a bit more of a crapshoot and the top school names simply aren’t the guarantee of quality they used to be. It’s a little easier to separate the wheat from the chaff at slightly lower ranked schools that actually do rank and do AOA and have some other ways to tell who the stars really are. After the dud above we fired, haven’t interviewed another student from that top school since.

 

[operaman]

I appreciate the sentiment of what you are trying to convey and understand where you are coming from. With that being said, this isn't something that is all consuming or keeping me up at night in the slightest. This is a forum designed for advice for medical students, as such, my post is tailored to my experiences on rotations and rotations alone, there is no use detailing my life outside of medicine and my ability to balance pleasure with work, every med student (and adult) may struggle with this in some form or another in life, but I have not had much issue finding a balance that works well for me and allows me to enjoy the things I like to do in life while succeeding in school.

My performance evaluators will be evaluating my performance, naturally I am going to be aware of, and pay attention to, their impressions of me while I am on service. While I'm not insinuating this is what you're directly advising, to not be concerned with how my evaluators perceive me at an institution where my evaluations make up a significant portion of my grade on the clerkship would be silly. I know the question I posed/advice I seek is not something unique to me or my institution, its a dilemma many students face. Sure, we can sit here and say it's the result of the system I am a part of, but that system is not going to be changing while I'm a student. To jump to conclusions about my mental health as a whole and my future ability to care for patients is quite a leap. I recognize where you are coming from, and agree that constantly focusing on other's perception of myself can be deleterious, no argument there. But to assume that's what I'm doing because I want to make the best impression on people who will have the final say on my grade is reaching.

Have no fear OP - that poster is a nitwit who has no idea what gunning even is. Sadly they’ve equates striving for excellence with gunning.

Gunning is where you actively and deliberately work to undermine other students to make yourself look better. It was like the away rotator we had (also from a T5) who emailed the team on behalf of all the students the day before the rotation to say hi and that they all had mandatory early orientation and wouldn’t be there until 10am. Then he alone comes running in early to be the only student at rounds that first morning. That’s gunning, and he kept it up the whole time and needless to say was never seen or heard from again at our program.

I don’t know where the idea of gunning morphed into describing any student who wants to be good. I suspect it’s largely schools moving to P/F such that old school gunning is less productive, so there’s just less of it to see. Old school gunning might be more akin to someone getting their peers to work less and study less and focus on their “mental health” while they quietly bust arse and crank out 270 step scores!

Wanting to grow clinically and having social awareness of how you’re being perceived is not remotely what we call gunning, and your mental health is going to be just fine.

 

[coffegroundemesis]

Nobody said gunning is even acceptable. It should be rooted out.

“Everyone basically starts fresh at the intern year.” This statement of yours implies that all interns are created equal which doesn’t correlate with reality.

Since we are talking about ranking, I go to a t5 as well.

Then what do you know about intern year? You are not even there. I am pretty confident that my clinical acumen is better than most of my classmates.

 

[Kierkegaard's Bud]

Then what do you know about intern year? You are not even there. I am pretty confident that my clinical acumen is better than most of my classmates.

Forget me, take heed operaman's earnest advice above.

 

[coffegroundemesis]

Forget me, take heed operaman's earnest advice above.

I am not in need of any advice. Every school has people like you, righteous puritan whom I do everything I can to avoid. Your every lead-in starts with “j’accuse..”

 

[coffegroundemesis]

Some of these posts remind me of the former T5 student we fired as a pgy2 who also had 99th percentile scores. He too had clearly blown off hard work and learning clinical medicine and just could not catch up and had the most terrible entitled attitude to boot. And I’ve seen the same pattern repeat in other programs and in other fields.

I think there is a certain level of knowledge and skill students need to have and it’s sad that education is not much of a priority even in top schools. Interns are not all created equal - not even all chiefs are equal. Some people are genuinely better than others and my experience has been that it’s correlated more with their innate intelligence and work ethic than anything else.

Sadly, intern quality coming out of T5 schools can be rather hit and miss. There are quite a few admits to these schools who get in because of a cool back story or to fill a quota and then get passed along and graduated with an MSPE that bends over backwards to obscure any indicator of how they compare to others.

Don’t get me wrong - lots of strong grads as well. It’s just a bit more of a crapshoot and the top school names simply aren’t the guarantee of quality they used to be. It’s a little easier to separate the wheat from the chaff at slightly lower ranked schools that actually do rank and do AOA and have some other ways to tell who the stars really are. After the dud above we fired, haven’t interviewed another student from that top school since.

Striving is not the only way to live.

 

[Angler]

I think that Knightdoc and Srirachamayo have been reincarnated.

 

[Moko]

Then what do you know about intern year? You are not even there. I am pretty confident that my clinical acumen is better than most of my classmates.

Clinical acumen and medical knowledge can always be taught. Attitude and teachability, not so much..

The best interns are those who are humble, honest/trustworthy, hard working, teachable, and have a positive attitude. Good clinical acumen is just the cherry on top. As one goes through training though, clinical acumen becomes more important, but that should not come at expense of the other qualities.

A new intern who is confident is just plain scary. Just my thoughts.

 

[ChordaEpiphany]

Med students don’t really learn anything anywhere, including the very top schools. Everyone basically starts fresh at the intern year. Medicine is just something that time will eventually teach you. No point to constantly try to leave an amazing impression on people. The performative nature of clerkship is quite ineffective and detrimental to a healthy development of a physician identity. I don’t think medical acumen is an issue at all. If you pass step 1 and 2, you have enough medical acumen to see almost all the patients. If you specialize, you will learn your specialty later on. The traditional thinking that medical school has to be grueling is so outdated and unnecessary. OP needs to focus on themselves instead of constantly worrying about how others perceive them. It’s bad for their mental health and eventually bad for the patients OP will eventually treat.

If med students learned nothing on the wards, then a brand new intern would be just as bad as a brand new M3. A brand new intern is rusty, terrified, and a bit lost, but at my institution they manage to cobble together halfway decent management plans for uncomplicated patients and juggle 6-7 patients on day 1 without having a complete mental breakdown. A brand new M3 barely knows how to introduce themselves. They've never used an EMR. They've got assessment in their subjective. They've got subjective in their plan. M3 is probably the biggest growth period aside from intern year in your journey as a physician.

Otherwise I strongly agree. The M3 learning curve is practically vertical. It says effectively nothing about your eventual growth as a physician and (more importantly) a leader in your field. So the focus on clinical performance is misplaced. On the wards, M3s are judged on their ability to learn easy things quickly and make an amazing first impression. In any real job, first impressions are important, but follow through, consistent hard work, and endearing yourself to long-term mentors is far more important. More important still is your dedication to lifelong learning. You have to memorize the common things in your specialty, but everyone does it, and whether that happens 3 months or 6 months into intern year has little significance on your eventual career as an attending. All med students are smart enough to be amazing attendings in all specialties. IMO, most of med school should be P/F. Maybe keep scored step 2 just to make sure people are actually motivated to study. Clinical years should start earlier, and sub-Is and aways (with a student on a single service for the entirety) should be the only evaluated part of clinical years. Residency applications should be about who can be clinically and academically competent while also multitasking to manage "above and beyond" achievements. I have classmates who took gap years to do prestigious fellowships (Fulbright, etc...), who started companies, who published research that wasn't resume-building trash, who earned grants for community projects, etc...

Honestly, who cares about the student who can rattle off third line antibiotic options for diverticulitis on their 2nd week of medicine? Why do we encourage students to be like this? In reality, clinically the best physicians will be those who are dedicated to getting better beyond when they are graded. Beyond clinically, the most impactful physicians will be those who can maintain clinical competence while juggling scalable side projects that influence their field and communities in a major way. The performative nature of M3 is one of the dumbest things I've experienced over several career paths.

 

[coffegroundemesis]

If med students learned nothing on the wards, then a brand new intern would be just as bad as a brand new M3. A brand new intern is rusty, terrified, and a bit lost, but at my institution they manage to cobble together halfway decent management plans for uncomplicated patients and juggle 6-7 patients on day 1 without having a complete mental breakdown. A brand new M3 barely knows how to introduce themselves. They've never used an EMR. They've got assessment in their subjective. They've got subjective in their plan. M3 is probably the biggest growth period aside from intern year in your journey as a physician.

Otherwise I strongly agree. The M3 learning curve is practically vertical. It says effectively nothing about your eventual growth as a physician and (more importantly) a leader in your field. So the focus on clinical performance is misplaced. On the wards, M3s are judged on their ability to learn easy things quickly and make an amazing first impression. In any real job, first impressions are important, but follow through, consistent hard work, and endearing yourself to long-term mentors is far more important. More important still is your dedication to lifelong learning. You have to memorize the common things in your specialty, but everyone does it, and whether that happens 3 months or 6 months into intern year has little significance on your eventual career as an attending. All med students are smart enough to be amazing attendings in all specialties. IMO, most of med school should be P/F. Maybe keep scored step 2 just to make sure people are actually motivated to study. Clinical years should start earlier, and sub-Is and aways (with a student on a single service for the entirety) should be the only evaluated part of clinical years. Residency applications should be about who can be clinically and academically competent while also multitasking to manage "above and beyond" achievements. I have classmates who took gap years to do prestigious fellowships (Fulbright, etc...), who started companies, who published research that wasn't resume-building trash, who earned grants for community projects, etc...

Honestly, who cares about the student who can rattle off third line antibiotic options for diverticulitis on their 2nd week of medicine? Why do we encourage students to be like this? In reality, clinically the best physicians will be those who are dedicated to getting better beyond when they are graded. Beyond clinically, the most impactful physicians will be those who can maintain clinical competence while juggling scalable side projects that influence their field and communities in a major way. The performative nature of M3 is one of the dumbest things I've experienced over several career paths.

I agree with you. You do learn how the hospital and clinical settings work as an MS3 and then almost all the medical knowledge comes from studying for the shelf. I didn’t really learn anything on the service that I haven’t learned through UW. Again, too much emphasis, hence the grading rubrics, have been put on the part of “clinical acumen” which, you said very well, develops in almost everyone whether it takes 3 months or 6 months. It’s like measuring the height of kindergartners to decide who should join the NBA. Then they perpetuate the idea that med school is the only time you will be able to accumulate knowledge. Tbh, most physicians are straight out lazy when they finish the training.

 

[ChordaEpiphany]

I didn’t really learn anything on the service that I haven’t learned through UW.

I'm definitely learning on the wards in a different way. Seeing it in practice often solidifies concepts in a way that you can't or won't pick up through UW, OME, youtube, etc... This is especially big for understanding: 1) prevalence, 2) threshold for management and diagnostic decisions (i.e., what tools do physicians actually use regularly vs. which ones gather dust), 3) prominent symptoms for a given presentation (i.e., if UWorld says disease A manifests with symptoms B, C, D, and E, which of those actually predominate in most or all patients?).

Do I believe this could be achieved with a solid resource that actually brought you through realistic cases? Sure. Is there a point to that when the hospital is overflowing with patients? Not really. Might as well drink from the source and absorb hospital culture simultaneously.

Again, too much emphasis, hence the grading rubrics, have been put on the part of “clinical acumen” which, you said very well, develops in almost everyone whether it takes 3 months or 6 months. It’s like measuring the height of kindergartners to decide who should join the NBA.

I love that analogy. The important stratification to make early on is who can handle the academic rigor of medical school/residency. The med school admission process already does a fantastic job. Maybe a more accurate analogy would be choosing the NBA based on middle school JV basketball tryouts, where you've got a mix of experienced players and generally athletic kids hitting the court for the first time. Like... at least let everyone get to a point where they know the rules of the game before we start throwing out recruiting star ratings.

That's why I'd rather see clinical grading based on sub-Is along with earlier clinical exposure in med school. Yes, we do need to be stratified somehow, but the first clinical year should be a time to learn, not a time to be constantly stressed about how competent you look doing something for the very first time in an unfamiliar environment.

Tbh, most physicians are straight out lazy when they finish the training.

Having worked outside of medicine, attendings are definitely not lazy. Doctors are just delusional when it comes to the work ethic of others and normal working conditions. Having worked in the startup world, at a big fortune 500, and in medicine, attending physicians are far-and-away the busiest moment-to-moment of any top-level manager. They also put in the most work improving themselves outside of their explicit job duties, even if it's only because the culture of medicine dictates that physicians, and not their employers, are responsible for keeping their knowledge current. In the corporate world, physicians would be taking a full 2-3 weeks off from the clinic yearly (with no reduction in pay) to attend conferences that keep them current.