Prep for Clinical Years

[ct303]

I begin clinical rotations at the end of the month. I am curious as to what advice any of you have? Also looking for suggestions on books or resources to read in preparation! Much appreciated.

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[mimelim]

http://forums.studentdoctor.net/thr...etent-fool-on-rotations.988111/#post-13752337

I just did evals for our medical students from February. Supposedly the clerkship director will edit/review them, but I kinda doubt it since what I wrote will be more detailed than he could ever write based on his interaction with them which was minimal.

I will only talk about surgery clerkships since that is what I know. A lot of this will apply to other clerkships that others can adapt. I can give specific examples for every single number below based on last month alone. These are very common issues.

To avoid being a bad student:
1) Show up on time
2) Look professional
3) Be available. You should never disapear and unreachable.
4) If asked to do something, either say, "Yes, I'll do it" or, "I don't feel comfortable with that, do you mind teaching me how to do it so I can do it next time?"
5) Do not ask "Anything that I can do right now?", ask, "How can I help?" or simply offer to do things, I hate scutting stuff to students, but if you offer to drop my notes off for me, or you feel comfortable finishing a dressing change on your own, if you say, "I can handle this" or just "I got this".

To be a good student:
1) Know your patients inside out and backwards. You are carrying less patients than your residents/attendings, you should know the details about your patient, even if they don't. You may not know what it means, but you should have the info available.
2) Always make an assessment, attempt to develop a plan. Start with a wide differential and focus in on the most likely diagnoses.
3) Read. Every night, even if it is for 15 minutes. Read about your patient or the procedure they are about to have or have had.
4) Be helpful. Getting labs, dropping notes in charts etc. Scut sucks, we all have to do it.
5) Tie and suture. I will walk anyone through how to do something, but I expect you to know the basics before showing up in the OR. If I show you how to do something, you should practice it at home and if you don't get it, ask me to show you again when we have down time.

To be a rock star:
1) Know your patients inside and out, but pay attention to what residents and attendings find important. Nobody will fault an MS3 for giving a laundry list of normal physical exam findings/labs, but eventually you have to learn to focus in on the important things so you can effectively communicate with colleagues down the road.
2) Develop skills. You are as useful as the skills that you posess. Things that an MS3 could potentially know how to do solo or with only resident observation:
a) Wet to dry dressings
b) Wound vac exchanges
c) Chest tube placements
d) Chest tube removals
e) Suturing - Simple, horizontal matress, vertical matress, sub Q, deep dermal, running
f) Central line placement
g) Central line removal
h) Fever workup
i) Getting outside hospital records
3) Learn to solve the common problems. Every rotation, go to the charge nurse on your main floor and ask them what the 10 most common intern calls are for. They should sound like this: Pain, fever, nausea, tachycardia, hypertension, electrolyte abnormalities etc. And then the specifics, Vascular: loss of previously dopplerable pulse, Gen Surg: change in abdominal exam findings etc. Then learn how to work up or manage those issues. As an MS4 on sub-I a good student will function like an intern. Those skills don't show up overnight, you have to develop them over time starting as an MS3.
4) Do not stop suturing or knot tieing. If you are interested in surgery, innate ability counts for something, but more important is practice. You should be able to do one handed ties left and right handed with ease. You should be efficient and accurate. When in conference, tie to your scrub bottoms or the chair next to you. If you have down time, have someone check your technique.
5) Think before cutting suture. What kind of suture are you cutting? Where are you cutting it? What is the purpose of this stitch? How many knots were tied? There is a logic behind suture tail length. While you will always have people that do things a particular way "just because", the vast majority will have a method behind their madness.

 

[christmasindr]

http://forums.studentdoctor.net/thr...etent-fool-on-rotations.988111/#post-13752337

I just did evals for our medical students from February. Supposedly the clerkship director will edit/review them, but I kinda doubt it since what I wrote will be more detailed than he could ever write based on his interaction with them which was minimal.

I will only talk about surgery clerkships since that is what I know. A lot of this will apply to other clerkships that others can adapt. I can give specific examples for every single number below based on last month alone. These are very common issues.

To avoid being a bad student:
1) Show up on time
2) Look professional
3) Be available. You should never disapear and unreachable.
4) If asked to do something, either say, "Yes, I'll do it" or, "I don't feel comfortable with that, do you mind teaching me how to do it so I can do it next time?"
5) Do not ask "Anything that I can do right now?", ask, "How can I help?" or simply offer to do things, I hate scutting stuff to students, but if you offer to drop my notes off for me, or you feel comfortable finishing a dressing change on your own, if you say, "I can handle this" or just "I got this".

To be a good student:
1) Know your patients inside out and backwards. You are carrying less patients than your residents/attendings, you should know the details about your patient, even if they don't. You may not know what it means, but you should have the info available.
2) Always make an assessment, attempt to develop a plan. Start with a wide differential and focus in on the most likely diagnoses.
3) Read. Every night, even if it is for 15 minutes. Read about your patient or the procedure they are about to have or have had.
4) Be helpful. Getting labs, dropping notes in charts etc. Scut sucks, we all have to do it.
5) Tie and suture. I will walk anyone through how to do something, but I expect you to know the basics before showing up in the OR. If I show you how to do something, you should practice it at home and if you don't get it, ask me to show you again when we have down time.

To be a rock star:
1) Know your patients inside and out, but pay attention to what residents and attendings find important. Nobody will fault an MS3 for giving a laundry list of normal physical exam findings/labs, but eventually you have to learn to focus in on the important things so you can effectively communicate with colleagues down the road.
2) Develop skills. You are as useful as the skills that you posess. Things that an MS3 could potentially know how to do solo or with only resident observation:
a) Wet to dry dressings
b) Wound vac exchanges
c) Chest tube placements
d) Chest tube removals
e) Suturing - Simple, horizontal matress, vertical matress, sub Q, deep dermal, running
f) Central line placement
g) Central line removal
h) Fever workup
i) Getting outside hospital records
3) Learn to solve the common problems. Every rotation, go to the charge nurse on your main floor and ask them what the 10 most common intern calls are for. They should sound like this: Pain, fever, nausea, tachycardia, hypertension, electrolyte abnormalities etc. And then the specifics, Vascular: loss of previously dopplerable pulse, Gen Surg: change in abdominal exam findings etc. Then learn how to work up or manage those issues. As an MS4 on sub-I a good student will function like an intern. Those skills don't show up overnight, you have to develop them over time starting as an MS3.
4) Do not stop suturing or knot tieing. If you are interested in surgery, innate ability counts for something, but more important is practice. You should be able to do one handed ties left and right handed with ease. You should be efficient and accurate. When in conference, tie to your scrub bottoms or the chair next to you. If you have down time, have someone check your technique.
5) Think before cutting suture. What kind of suture are you cutting? Where are you cutting it? What is the purpose of this stitch? How many knots were tied? There is a logic behind suture tail length. While you will always have people that do things a particular way "just because", the vast majority will have a method behind their madness.

I did not know an MS3 is expected to know how to do chest tube placement/removal and central line placement...

 

[mimelim]

I did not know an MS3 is expected to know how to do chest tube placement/removal and central line placement...

There is substantial difference between "expected to know how" and "potentially know how to do solo or with only resident observation". I said one of those, you said the other.

I had an MS3 with me on call several weekends ago and they did the entire central line that we did together. I was sterile, watching them and handed them whatever they asked for. Off of the sterile table. These are very simple procedures that require reasonable hands, but there is nothing special about an intern vs. MS3 vs. high school student. What is much more important and more difficult is understand when/why you are doing these procedures. Then the MOST important step is developing the skill to make decisions on who should or more importantly, should not get the procedure. For example, that same weekend, my intern took a page from a medicine service for a central line, which she agreed to do for them. I went to see the patient with her and after talking with the medicine team again, declined to place the central line and instead placed an ultrasound guided EJ PIV which is more appropriate for what they needed. I don't expect that MS3 to make that decision and take it up with a hospitalist themselves. I expect my intern to learn from that experience and add it to her armamentarium.

The vast majority of medical students are not going into surgical specialties. Even those going into surgical specialties are not always particularly motivated to pick up those skills. But, for highly motivated students in the right environment, why not? My intern has 40+ central lines under her belt and has no interest in doing a line for the sake of it. If there is a patient with a chip-shot vein and has shown a particular interest and aptitude, there is no magic behind doing these things. See one, talk about it, then watch me do another one, but this time tell me each step before I do it, then do all of the non-critical portions of the procedure (in the case of central line, everything except sticking the vein and dilating the track), then next time take over under supervision.

 

[christmasindr]

There is substantial difference between "expected to know how" and "potentially know how to do solo or with only resident observation". I said one of those, you said the other.

I had an MS3 with me on call several weekends ago and they did the entire central line that we did together. I was sterile, watching them and handed them whatever they asked for. Off of the sterile table. These are very simple procedures that require reasonable hands, but there is nothing special about an intern vs. MS3 vs. high school student. What is much more important and more difficult is understand when/why you are doing these procedures. Then the MOST important step is developing the skill to make decisions on who should or more importantly, should not get the procedure. For example, that same weekend, my intern took a page from a medicine service for a central line, which she agreed to do for them. I went to see the patient with her and after talking with the medicine team again, declined to place the central line and instead placed an ultrasound guided EJ PIV which is more appropriate for what they needed. I don't expect that MS3 to make that decision and take it up with a hospitalist themselves. I expect my intern to learn from that experience and add it to her armamentarium.

The vast majority of medical students are not going into surgical specialties. Even those going into surgical specialties are not always particularly motivated to pick up those skills. But, for highly motivated students in the right environment, why not? My intern has 40+ central lines under her belt and has no interest in doing a line for the sake of it. If there is a patient with a chip-shot vein and has shown a particular interest and aptitude, there is no magic behind doing these things. See one, talk about it, then watch me do another one, but this time tell me each step before I do it, then do all of the non-critical portions of the procedure (in the case of central line, everything except sticking the vein and dilating the track), then next time take over under supervision.

Sounds like fun! Thanks for sharing. It is a bit intimidating going into MS3.

 

[Gambler 101]

I found First Aid for the Wards helpful. It just tells you what skills you need, note samples, etc for each rotation


Sent from my iPhone using SDN mobile

 

[sloop]

To be honest, just do your best to appear interested and be willing to learn.

A lot of this stuff depends on who's evaluating you and to be perfectly honest, some places you go it won't matter because the rotation structure sucks, you barely get to spend a significant amount of time with anyone, and when you're graded by these people who barely know you and have a substantial amount of other paperwork on their plates, you will get whatever that person considers their "standard grade" + generic comments. It sucks but it is what it is at some places—if you get stuck at one of these places, I'd just try to learn and study for the shelf because you'll barely be with the same person twice to get pimped on anything predictable/based on a past patient. The rest of what I will recommend only matters for places where this isn't the case.

Try to read and know about the bread and butter stuff in the specialty you're rotating in. Most of the time, the really esoteric pimp questions are meant to teach a point and you're not actually being evaluated on your knowledge (bonus points if you know them though). Don't worry too much about getting these wrong. Depending on the question, it is very appropriate to say "I don't know." I've said that several times and had attendings literally say "Right answer! Now let me explain how . . . " Other times, you may not explicitly know the answer but you feel like you can take a shot based on principles you know. In that case I have often said "I'm not really sure this is right, but maybe it could be that . . . " A lot of attendings appreciate the humility but also appreciate that you took a shot at the question.

If you find someone who is nice and willing to consistently teach you, grab onto them for dear life and ask them as many questions they you have. Ask them to teach you and give them honest and thorough thanks when they do. This will usually be an upper level resident, but can be almost anyone. To be brutally honest, most residents suck at educating and if you find one who is good at it, take advantage. The interest you show will also almost certainly make its way to your evaluation.

You will get questions about what your specialty of interest is. You can feel free to be vague at the beginning of the year if you're worried about being perceived as uninterested—"I think I might like X, but I am still open to changing my mind and I think [current specialty] has a lot of things I might like too, [+/- particularly, I am looking forward to experiencing Y&Z on this rotation]." If you're past the midway point in third year, though, don't do this. At that point it's perceived as way weirder to have no goddamned clue what you want to do than it is to express a passionate interest in something that is unrelated to the current rotation. I think I transitioned to "I'm interested in X, but I want to be the best physician I can be and I want to learn as much as possible about [current specialty] while I'm here."

Some people minimize the importance of being diplomatic about your answer to this question and others I think overemphasize it. I think I'm somewhere in the middle. However, I also knew very early that I wanted psychiatry, and as ****ty as it is people do sometimes treat you differently if you say you like psych without expressing explicit interest in other specialties despite that. A lot of it is well intentioned, but I've gotten responses like "oh, well, I guess none of this will really be useful to you, then" before. Sometimes this will lead to people involving you in things (procedures, etc) less spontaneously until you tell them that you want this. All of this is just to say, be diplomatic and express some interest when bringing up this topic.

 

[mimelim]

To be honest, just do your best to appear interested and be willing to learn.

A lot of this stuff depends on who's evaluating you and to be perfectly honest, some places you go it won't matter because the rotation structure sucks, you barely get to spend a significant amount of time with anyone, and when you're graded by these people who barely know you and have a substantial amount of other paperwork on their plates, you will get whatever that person considers their "standard grade" + generic comments. It sucks but it is what it is at some places—if you get stuck at one of these places, I'd just try to learn and study for the shelf because you'll barely be with the same person twice to get pimped on anything predictable/based on a past patient. The rest of what I will recommend only matters for places where this isn't the case.

Try to read and know about the bread and butter stuff in the specialty you're rotating in. Most of the time, the really esoteric pimp questions are meant to teach a point and you're not actually being evaluated on your knowledge (bonus points if you know them though). Don't worry too much about getting these wrong. Depending on the question, it is very appropriate to say "I don't know." I've said that several times and had attendings literally say "Right answer! Now let me explain how . . . " Other times, you may not explicitly know the answer but you feel like you can take a shot based on principles you know. In that case I have often said "I'm not really sure this is right, but maybe it could be that . . . " A lot of attendings appreciate the humility but also appreciate that you took a shot at the question.

If you find someone who is nice and willing to consistently teach you, grab onto them for dear life and ask them as many questions they you have. Ask them to teach you and give them honest and thorough thanks when they do. This will usually be an upper level resident, but can be almost anyone. To be brutally honest, most residents suck at educating and if you find one who is good at it, take advantage. The interest you show will also almost certainly make its way to your evaluation.

You will get questions about what your specialty of interest is. You can feel free to be vague at the beginning of the year if you're worried about being perceived as uninterested—"I think I might like X, but I am still open to changing my mind and I think [current specialty] has a lot of things I might like too, [+/- particularly, I am looking forward to experiencing Y&Z on this rotation]." If you're past the midway point in third year, though, don't do this. At that point it's perceived as way weirder to have no goddamned clue what you want to do than it is to express a passionate interest in something that is unrelated to the current rotation. I think I transitioned to "I'm interested in X, but I want to be the best physician I can be and I want to learn as much as possible about [current specialty] while I'm here."

Some people minimize the importance of being diplomatic about your answer to this question and others I think overemphasize it. I think I'm somewhere in the middle. However, I also knew very early that I wanted psychiatry, and as ****ty as it is people do sometimes treat you differently if you say you like psych without expressing explicit interest in other specialties despite that. A lot of it is well intentioned, but I've gotten responses like "oh, well, I guess none of this will really be useful to you, then" before. Sometimes this will lead to people involving you in things (procedures, etc) less spontaneously until you tell them that you want this. All of this is just to say, be diplomatic and express some interest when bringing up this topic.

I agree. If I know what someone is going into if I see something that might interest them, I'm going to push it toward them. But, if you are on surgery with a bunch of people that know they are going into surgery, it is going to be tough to get hands on time, especially if you aren't around as much as they typically are.

 

[Psai]

There is substantial difference between "expected to know how" and "potentially know how to do solo or with only resident observation". I said one of those, you said the other.

I had an MS3 with me on call several weekends ago and they did the entire central line that we did together. I was sterile, watching them and handed them whatever they asked for. Off of the sterile table. These are very simple procedures that require reasonable hands, but there is nothing special about an intern vs. MS3 vs. high school student. What is much more important and more difficult is understand when/why you are doing these procedures. Then the MOST important step is developing the skill to make decisions on who should or more importantly, should not get the procedure. For example, that same weekend, my intern took a page from a medicine service for a central line, which she agreed to do for them. I went to see the patient with her and after talking with the medicine team again, declined to place the central line and instead placed an ultrasound guided EJ PIV which is more appropriate for what they needed. I don't expect that MS3 to make that decision and take it up with a hospitalist themselves. I expect my intern to learn from that experience and add it to her armamentarium.

The vast majority of medical students are not going into surgical specialties. Even those going into surgical specialties are not always particularly motivated to pick up those skills. But, for highly motivated students in the right environment, why not? My intern has 40+ central lines under her belt and has no interest in doing a line for the sake of it. If there is a patient with a chip-shot vein and has shown a particular interest and aptitude, there is no magic behind doing these things. See one, talk about it, then watch me do another one, but this time tell me each step before I do it, then do all of the non-critical portions of the procedure (in the case of central line, everything except sticking the vein and dilating the track), then next time take over under supervision.

God my rotation sucked. I was in the or all day. Literally all day

 

[ortnakas]

@mimelim, thank you for your detailed and really thoughtful post!

Would you mind going into what you'd expect an MS-III to know on day/week 1? I have surgery as my very first rotation this summer. We've had a few very short labs this year on things like suturing, but I'm not sure I actually retained anything useful. I don't foresee going into surgery, but I want to learn a lot and I want to do well.

 

[Hangry]

I begin clinical rotations at the end of the month. I am curious as to what advice any of you have? Also looking for suggestions on books or resources to read in preparation! Much appreciated.

Books and resource advice are found in the "clinical rotations" forum, typically in the "XYZ shelf exam" threads.

Best advice I have is study early and often. I always did some prereading the weekend (okay honestly sunday) before a rotation, and then planned out a study plan where I had to accomplish X things in a given day (eg X number of uworld questions, X pages in a textbook, and 1-2 onlinemeded videos). I would do that every day, including weekends (not necessary but I'm a bit OCD) and never once had to stress about a shelf. In fact I would rarely study at all the last few days before a shelf because by that point I was burned out of the rotation and was already plenty prepared.

The reason you need to do this early (from day 1) is that 1) it helps you look good to your attendings when you have a decent knowledge base, you can ask relatively knowledgable questions from week 1 rather than looking like a total n00b (which makes you look interested in the field), 2) it makes the rotation much more fun and easier to engage with when conversations aren't going completely over your head and you can follow along the decision making trains of thought and even provide some input, and 3) repetition over time is far better for retention than cramming (and with as busy as third year is you need to study as effectively as possible. Oh and theres a little thing called step II CK at the end). Sure you can cram at the end at hit a decent shelf score especially if you test well, but you will miss out on all the other benefits and likely have worse clinical evals which at many schools are worth more than the shelf score.

Finally expect to be completely overwhelmed. There is so much new to learn in third year that you don't realize you don't know in the first two regarding functioning in a hospital (how does the hierarchy work, how does the hospital work communication, how do I page someone from a phone, where is the bathroom, how do I interview a patient, how do I use epic, where is the ED, how do I write a note, what things is it appropriate for me to discuss with a patient, how much of the physical exam should you do this encounter, how do I scrub/gown/glove, etc etc). And much of that changes depending on what site you are at. Just try to ride the wave, I promise that everyone else is overwhelmed too, no matter how much they are trying to hide it. You just have to be okay with uncertainty and saying I don't know/asking questions over and over. You will find your sweet spot. Even for me, at the end of third year, I know my first 1.5 weeks at a site are going to SUCK, but after that I hit my stride.

Try to enjoy it as best you can. There are aspects of third year that are far better than the first two, and some that are worse. Focus on the positives and you should have a pretty good time and learn more than you thought possible.

 

[sinombre]

Sounds like fun! Thanks for sharing. It is a bit intimidating going into MS3.

Also keep in mind the student he was with is at the end of third year. Everyone starts out nervous and everyone becomes much more confident as the year goes on.

 

[mimelim]

@mimelim, thank you for your detailed and really thoughtful post!

Would you mind going into what you'd expect an MS-III to know on day/week 1? I have surgery as my very first rotation this summer. We've had a few very short labs this year on things like suturing, but I'm not sure I actually retained anything useful. I don't foresee going into surgery, but I want to learn a lot and I want to do well.

Every school is going to be different and how the orientate people will be different. Two things that will maximize what you get out of the rotations...

#1 Basic skills. Learn to knot tie. I used to run a suture workshop for MS1-3s. Once a week, just sit down and people can goof around with instruments/suture on fake skin. Practice knots, different stitches, etc. Most schools will have something like this. If they don't, just find an MS3/4 ahead of you and ask them to do the basics. Even if you aren't going into surgery, it will go a long way to be able to at least tie and have some sense of the different types of sutures. I think that it is reasonable to review your basic anatomy based on what you are going to be doing. For example, if you are starting with 2 weeks of ortho, it is probably worthwhile to go over some of the joints/muscles. If you are on a general surgery service, review the abdomen, etc. Nothing big, just so that when people are throwing out terms, it isn't completely foreign.

#2 While on rotation, read every day. Even if you did 16 hours, force yourself to read for 15 minutes while eating or right before going to sleep. It adds up and if you can force yourself to do it on the ****ty days, you will be more likely to do it on the normal days.

Also keep in mind the student he was with is at the end of third year. Everyone starts out nervous and everyone becomes much more confident as the year goes on.

This is definitely an important point and it extends into residency as well. A July intern is not nearly the same as a May intern from most perspectives.