Top 10 tips for a "Top 10" SLOE

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emfeller

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Hey all – I have no idea if this will be helpful or not, but here goes. I created a separate sdn account in case this comes across the wrong way. I do not want this to come across as bragging—I apologize if it does. I instead want to provide something that might be helpful to other medical students trying to figure out a way to match into this increasingly competitive specialty.

First off – SLOEs (Standardized Letters of Evaluation) are extremely important. Ask anyone who has gone through the application process, and they’ll tell you that SLOEs will make or break your application. Also this (Council of Emergency Medicine Residency Directors' standardized letter of recommendation: the program director's perspective, search pubmed id: 25039553) and this (Factors Affecting Candidate Placement on an Emergency Medicine Residency Program’s Rank Order List, search pubmed id: PMC3555575). Sorry I can't post links because this is a new account.

Second, my qualifications – I was a relatively average medical student in terms of Step scores, clinical grades, and other factors. I did two EM rotations (a home and an away). Both were at fairly strong programs and I received “Top 10” SLOEs from both. There’s no way to know for certain what’s on your own SLOE, but I was told by interviewers while on the residency interview trail that both of my SLOEs were top 10, and within the comments on one of them it noted that I was among the best students to have rotated. As we all know, a large component of your evaluations just comes down to the luck of who’s evaluating you. So one could argue that maybe I was just an average EM student who happened to get lucky with easy evaluators. I can’t prove you wrong. Nonetheless, I’ll share my approach to the rotations and maybe it will help.

Alright let’s get down to business. Because I was such an average student I knew I’d have to work very hard to do well on my SLOEs. Here are my tips for others like me:

1. Keep a positive, friendly attitude
This cannot be overemphasized. It’s really hard for them to assess your knowledge on an 8/10/12 hour shift, but it’s easy for them to see how you behave. Be considerate. Don’t eat the last donut. Try not to sit at someone’s workstation. If your shift is busy, don’t complain about the work. In fact, try not to complain about anything (use your judgment – obviously things like abuse, unethical practice, etc. need to be brought up!) I witnessed other students speak negatively about patients and nurses. Don’t do that ever. Don’t jump to the conclusion that a patient is faking their pain and then present the patient like they’re a jerk. Give them the benefit of the doubt and then say in your assessment that you think the clinical picture is inconsistent and the patient may be malingering because x,y,z.

Be enthusiastic about learning opportunities. If your shift is over and you’re exhausted and a resident says “oh hey we’re about to put in a central line on this guy, want to help?” you should respond “yeah!” unless you have to pick up your grandma at the airport or something.

2. Listen to podcasts
Such as emclerkship, or embasic, there are several out there. I listened to emclerkship the most because it seemed the most tailored to medical students. Listen in your car or while you’re exercising.

3. Create a cheat sheet
It’s hard to interview a patient, examine them, collect your thoughts, and come up with a plan all in 10-15 minutes, then give a coherent and brief presentation to the resident/attending. Some of my classmates could do this without taking notes or referring to guidelines. I had to rely on what I called my “cheat sheets”. There were two of them:

i) Cheat sheet #1: A double sided piece of paper which had on one side a bunch of common presenting complaints and their major considerations, common workups, and treatments. Think of these as little “workup consults” to refer to when thinking about a chief complaint. For example, here’s what I have written for priapism:

“PRIAPISM: N/A/V at 12 o'clock, urethra at 6 o'clock
Painful? (low flow, ischemic) vs not painful? (high flow, non-ischemic)
-Ischemic: plan for bedside detumescence, caused by SCD, drugs
-Non-ischemic: Plan for Urology cs, caused by trauma, AV malf, mass
Obtain 19g & 21g needles, syringes, gauze, sterile drape, NS, chlorhex
Perform penile nerve block
Aspirate w 19g at 3 or 9 o'clock, irrigate w 21g at more proximal point
Inject 0.25ml of 1mg/ml phenylephrine q10 min”

I had this for chest pain, abdominal pain, headache, syncope, AMS, vertigo, asthma, COPD, CHF, head/neck/leg injury, lacerations, fractures, burns, vaginal bleeding, torsion & other testicular complaints, epistaxis, sickle cell, dental pain, DKA, hyperkalemia, hyponatremia, psych, sepsis, and on and on… (I have my document in Excel and the font is very small but it’s easy to fit all these on one side of the paper)

I wrote a lot of these little “workup consults” using the podcasts (tip #2 above). As each rotation progressed I would make additions or modifications based on what I learned from residents. There were multiple times when I looked like a freaking genius but really all I had done was refer to my cheat sheet before seeing each patient. Like diagnosing and treating a periapical abscess (thanks EMclerkship! check out the episode on Dental Pain).

On the other side were a few different clinical decision tools and their point systems (e.g. PERC, HEART, Wells, CURB-65, CHESS, Canadian head CT, etc.) as well as some differentials for complaints that have a wide differential (e.g. AMS, abdominal pain). These weren’t used a whole lot but it was still helpful to refer to them from time to time.​

ii) Cheat sheet #2: This was just an H&P note-taking sheet like ones you’ve probably used or seen other students/residents using. I customized my own as follows (the font was very small so I could fit everything): HPI section, with reminders for specific questions to ask patients with chest pain, SOB, AMS, HA, dizziness. A review of systems section with symptoms to ask about depending on the patient’s complaint, organized by system. A PMH/PSH section. Meds/Allergies section. Fam hx/social/smoking/etoh/drugs/other section. Vitals/Phys exam section. Labs/imaging/studies section. Assessment/Plan section. And importantly, a dispo section – should the patient be admitted/discharged/depending on what?

A lot of people are good enough to not use a note-taking sheet like this. I found that I could present without one if needed, but sometimes I’d leave out an important exam finding, or I’d forget to mention the EKG or whatever. I wanted to be thorough. It definitely looks a lot “smoother” if you can just present on the fly without looking down at a sheet of paper. Kudos to those who can do well that way, I just wasn’t good enough.

As I mentioned, I made the font small. I could fit one of these on a half sheet of paper so I was using 1 double sided sheet for 4 patients.​

4. Keep your presentations brief
Unless told otherwise, keep them extremely brief. Yes, my note-taking sheet had a section for family history, but I used it probably like 1% of the time. If it’s not relevant to why the patient is in the ED, don’t bring it up.

When describing pain try to cram a bunch of descriptors into 1 sentence. “Patient reports a sharp 9/10 intermittent non-radiating pain in her RUQ that’s worse after eating and not relieved by motrin.” rather than “patient reports a pain in her RUQ that she says is as bad as 9/10 but sometimes 7/10, that she describes as sharp. It doesn’t radiate. It comes and goes. She feels like it’s worse after eating. She tried taking motrin but had minimal relief.”

Then report the pertinent positives & negatives. I’d usually say something like: “Associated with nausea and 1 episode of NBNB vomiting. She denies fevers, diarrhea, reflux, CP, SOB, etc.” Don’t go on forever with pertinent negatives.

5. Anticipate anticipate anticipate
This was always difficult for me on my clinical rotations. As med students we’re always trying to anticipate the resident’s needs and address them early so that it makes their lives easier. On my EM rotations, I paid close attention to supply needs. When doing an LP/central line/whatever, there are often procedure kits that you’ll want to grab. But these don’t contain everything. You’ll need to get gowns/gloves etc, probably an extra syringe & needle, maybe some extra sterile towels or whatever. The first time you do a procedure with a resident take note of everything they needed to get from the supply closet. Next time you need to do that procedure, grab everything ahead of time.

There are other ways you can anticipate what’s needed. You see a patient with a vaginal complaint? Grab all the items you need for a pelvic exam and put them in the room. Go find your resident and present. See the patient together, boom everything is there waiting for you to do the exam. You see a patient with RUQ pain that you think needs an U/S? Finish the interview, grab the ultrasound if it’s available, put it in the patient’s room. Go find your resident and present. Mention that the u/s is in the room ready for whenever they’d like to do it, and you’ve already entered the patient’s information into the machine.

6. Follow your patients
Easier said than done. You order some labs or some imaging, then move on to the next patient and forget about everything. Always be checking the test results of patients you’ve seen and update the resident. Most of the time he/she has already seen the result but sometimes you’ll be the first person to notice an abnormality and it’s nice to give the resident a heads up. Don’t just report the results, though. Report the results and follow it with “so would you think it’d be a good idea to treat with x?” Have a plan based on what test results show.

Check in on your patients. One of the better things you can report to a resident is “hey I checked in on our migraine girl in room 8 and her pain is down to a 2/10, says she’s OK going home”. A good time to check in on old patients is right after you’ve presented a new patient, before you pick up another one. If you feel like it you can mention “hey I’m just gonna go check in on so-and-so in room 12.”

7. Be flexible
Some programs have you work with the same resident the whole month, but most will have you working with a different resident/attending almost every shift. Each may take a completely different approach from the next as far as how they work with medical students. Maybe your last resident let you go in the room first and then pend orders, and this one just has you shadow, or they come in the room 2 minutes after you started interviewing the patient and totally take over the interview. That can be frustrating but don’t sweat it. It’s not about you.

They will also have different styles when it comes to patients and their workups. For example, many residents have a physical exam maneuver or two that they love to use. I had a resident that asked an elderly back pain patient to get out of bed and stand on heels & toes (an important strength test that is often rushed through in favor of having them stay laying down and “push down on the gas pedal” – I’m sure some of you know what I’m talking about)… few hours later, we had another elderly patient with back pain. I made sure to do that exact maneuver and report the results when presenting. Little details like that will show you’re paying attention and trying to get better.

8. Show up early
Show up at least 15 minutes early to every shift ready to go. If you’re on a rotation where medical students start shifts at the same time as residents, pay attention to when the residents arrive. At one of my rotations the residents always started seeing patients about 15 minutes before their official shift start time, so I started arriving at least 20 minutes early. This does not go unnoticed! Also, be ready to go as soon as you arrive. If your shift starts at 12 and you get there at 11:30 thinking you’re gonna set your bag down and go buy coffee, but your resident spots you and tells you to see the patient in room 20, you forget the dang coffee and go see that patient no questions asked!

You might have a slow shift where the resident says “hey it looks like things are slowing down, you should take off”. There’s no need to argue or pretend like you want to stay forever. A simple “is there anything else I can help you with” is cool, then take advantage of the early release.

9. Be yourself
Duh, right? But here’s my point. The “3 AM” test is real. If you’re not familiar, this refers to how residents/attendings assess whether they could tolerate being stuck with someone on a dull overnight shift at 3 AM with nothing to do. If you don’t pass their “3 AM” test, (i.e. they don’t find you friendly/personable/interesting) they’re less likely to rank you highly. This means when you and your resident aren’t working on something, have normal conversations with them. Ask them how their weekend was, etc. Sounds silly, but just be a normal person, haha.

10. Work your ass off
You get what, 16 or so shifts on a rotation to show them what you’ve got? Don’t half-ass a single shift.

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9. Be yourself
Duh, right? But here’s my point. The “3 AM” test is real. If you’re not familiar, this refers to how residents/attendings assess whether they could tolerate being stuck with someone on a dull overnight shift at 3 AM with nothing to do. If you don’t pass their “3 AM” test, (i.e. they don’t find you friendly/personable/interesting) they’re less likely to rank you highly. This means when you and your resident aren’t working on something, have normal conversations with them. Ask them how their weekend was, etc. Sounds silly, but just be a normal person, haha.

10. Work your ass off
You get what, 16 or so shifts on a rotation to show them what you’ve got? Don’t half-ass a single shift.

Great advice. I call #9 the elevator test. Could I tolerate being stuck on an elevator with the person while awaiting to be rescued.
 
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Hey all – I have no idea if this will be helpful or not, but here goes. I created a separate sdn account in case this comes across the wrong way. I do not want this to come across as bragging—I apologize if it does. I instead want to provide something that might be helpful to other medical students trying to figure out a way to match into this increasingly competitive specialty.

First off – SLOEs (Standardized Letters of Evaluation) are extremely important. Ask anyone who has gone through the application process, and they’ll tell you that SLOEs will make or break your application. Also this (Council of Emergency Medicine Residency Directors' standardized letter of recommendation: the program director's perspective, search pubmed id: 25039553) and this (Factors Affecting Candidate Placement on an Emergency Medicine Residency Program’s Rank Order List, search pubmed id: PMC3555575). Sorry I can't post links because this is a new account.

Second, my qualifications – I was a relatively average medical student in terms of Step scores, clinical grades, and other factors. I did two EM rotations (a home and an away). Both were at fairly strong programs and I received “Top 10” SLOEs from both. There’s no way to know for certain what’s on your own SLOE, but I was told by interviewers while on the residency interview trail that both of my SLOEs were top 10, and within the comments on one of them it noted that I was among the best students to have rotated. As we all know, a large component of your evaluations just comes down to the luck of who’s evaluating you. So one could argue that maybe I was just an average EM student who happened to get lucky with easy evaluators. I can’t prove you wrong. Nonetheless, I’ll share my approach to the rotations and maybe it will help.

Alright let’s get down to business. Because I was such an average student I knew I’d have to work very hard to do well on my SLOEs. Here are my tips for others like me:

1. Keep a positive, friendly attitude
This cannot be overemphasized. It’s really hard for them to assess your knowledge on an 8/10/12 hour shift, but it’s easy for them to see how you behave. Be considerate. Don’t eat the last donut. Try not to sit at someone’s workstation. If your shift is busy, don’t complain about the work. In fact, try not to complain about anything (use your judgment – obviously things like abuse, unethical practice, etc. need to be brought up!) I witnessed other students speak negatively about patients and nurses. Don’t do that ever. Don’t jump to the conclusion that a patient is faking their pain and then present the patient like they’re a jerk. Give them the benefit of the doubt and then say in your assessment that you think the clinical picture is inconsistent and the patient may be malingering because x,y,z.

Be enthusiastic about learning opportunities. If your shift is over and you’re exhausted and a resident says “oh hey we’re about to put in a central line on this guy, want to help?” you should respond “yeah!” unless you have to pick up your grandma at the airport or something.

2. Listen to podcasts
Such as emclerkship, or embasic, there are several out there. I listened to emclerkship the most because it seemed the most tailored to medical students. Listen in your car or while you’re exercising.

3. Create a cheat sheet
It’s hard to interview a patient, examine them, collect your thoughts, and come up with a plan all in 10-15 minutes, then give a coherent and brief presentation to the resident/attending. Some of my classmates could do this without taking notes or referring to guidelines. I had to rely on what I called my “cheat sheets”. There were two of them:

i) Cheat sheet #1: A double sided piece of paper which had on one side a bunch of common presenting complaints and their major considerations, common workups, and treatments. Think of these as little “workup consults” to refer to when thinking about a chief complaint. For example, here’s what I have written for priapism:

“PRIAPISM: N/A/V at 12 o'clock, urethra at 6 o'clock
Painful? (low flow, ischemic) vs not painful? (high flow, non-ischemic)
-Ischemic: plan for bedside detumescence, caused by SCD, drugs
-Non-ischemic: Plan for Urology cs, caused by trauma, AV malf, mass
Obtain 19g & 21g needles, syringes, gauze, sterile drape, NS, chlorhex
Perform penile nerve block
Aspirate w 19g at 3 or 9 o'clock, irrigate w 21g at more proximal point
Inject 0.25ml of 1mg/ml phenylephrine q10 min”

I had this for chest pain, abdominal pain, headache, syncope, AMS, vertigo, asthma, COPD, CHF, head/neck/leg injury, lacerations, fractures, burns, vaginal bleeding, torsion & other testicular complaints, epistaxis, sickle cell, dental pain, DKA, hyperkalemia, hyponatremia, psych, sepsis, and on and on… (I have my document in Excel and the font is very small but it’s easy to fit all these on one side of the paper)

I wrote a lot of these little “workup consults” using the podcasts (tip #2 above). As each rotation progressed I would make additions or modifications based on what I learned from residents. There were multiple times when I looked like a freaking genius but really all I had done was refer to my cheat sheet before seeing each patient. Like diagnosing and treating a periapical abscess (thanks EMclerkship! check out the episode on Dental Pain).

On the other side were a few different clinical decision tools and their point systems (e.g. PERC, HEART, Wells, CURB-65, CHESS, Canadian head CT, etc.) as well as some differentials for complaints that have a wide differential (e.g. AMS, abdominal pain). These weren’t used a whole lot but it was still helpful to refer to them from time to time.​

ii) Cheat sheet #2: This was just an H&P note-taking sheet like ones you’ve probably used or seen other students/residents using. I customized my own as follows (the font was very small so I could fit everything): HPI section, with reminders for specific questions to ask patients with chest pain, SOB, AMS, HA, dizziness. A review of systems section with symptoms to ask about depending on the patient’s complaint, organized by system. A PMH/PSH section. Meds/Allergies section. Fam hx/social/smoking/etoh/drugs/other section. Vitals/Phys exam section. Labs/imaging/studies section. Assessment/Plan section. And importantly, a dispo section – should the patient be admitted/discharged/depending on what?

A lot of people are good enough to not use a note-taking sheet like this. I found that I could present without one if needed, but sometimes I’d leave out an important exam finding, or I’d forget to mention the EKG or whatever. I wanted to be thorough. It definitely looks a lot “smoother” if you can just present on the fly without looking down at a sheet of paper. Kudos to those who can do well that way, I just wasn’t good enough.

As I mentioned, I made the font small. I could fit one of these on a half sheet of paper so I was using 1 double sided sheet for 4 patients.​

4. Keep your presentations brief
Unless told otherwise, keep them extremely brief. Yes, my note-taking sheet had a section for family history, but I used it probably like 1% of the time. If it’s not relevant to why the patient is in the ED, don’t bring it up.

When describing pain try to cram a bunch of descriptors into 1 sentence. “Patient reports a sharp 9/10 intermittent non-radiating pain in her RUQ that’s worse after eating and not relieved by motrin.” rather than “patient reports a pain in her RUQ that she says is as bad as 9/10 but sometimes 7/10, that she describes as sharp. It doesn’t radiate. It comes and goes. She feels like it’s worse after eating. She tried taking motrin but had minimal relief.”

Then report the pertinent positives & negatives. I’d usually say something like: “Associated with nausea and 1 episode of NBNB vomiting. She denies fevers, diarrhea, reflux, CP, SOB, etc.” Don’t go on forever with pertinent negatives.

5. Anticipate anticipate anticipate
This was always difficult for me on my clinical rotations. As med students we’re always trying to anticipate the resident’s needs and address them early so that it makes their lives easier. On my EM rotations, I paid close attention to supply needs. When doing an LP/central line/whatever, there are often procedure kits that you’ll want to grab. But these don’t contain everything. You’ll need to get gowns/gloves etc, probably an extra syringe & needle, maybe some extra sterile towels or whatever. The first time you do a procedure with a resident take note of everything they needed to get from the supply closet. Next time you need to do that procedure, grab everything ahead of time.

There are other ways you can anticipate what’s needed. You see a patient with a vaginal complaint? Grab all the items you need for a pelvic exam and put them in the room. Go find your resident and present. See the patient together, boom everything is there waiting for you to do the exam. You see a patient with RUQ pain that you think needs an U/S? Finish the interview, grab the ultrasound if it’s available, put it in the patient’s room. Go find your resident and present. Mention that the u/s is in the room ready for whenever they’d like to do it, and you’ve already entered the patient’s information into the machine.

6. Follow your patients
Easier said than done. You order some labs or some imaging, then move on to the next patient and forget about everything. Always be checking the test results of patients you’ve seen and update the resident. Most of the time he/she has already seen the result but sometimes you’ll be the first person to notice an abnormality and it’s nice to give the resident a heads up. Don’t just report the results, though. Report the results and follow it with “so would you think it’d be a good idea to treat with x?” Have a plan based on what test results show.

Check in on your patients. One of the better things you can report to a resident is “hey I checked in on our migraine girl in room 8 and her pain is down to a 2/10, says she’s OK going home”. A good time to check in on old patients is right after you’ve presented a new patient, before you pick up another one. If you feel like it you can mention “hey I’m just gonna go check in on so-and-so in room 12.”

7. Be flexible
Some programs have you work with the same resident the whole month, but most will have you working with a different resident/attending almost every shift. Each may take a completely different approach from the next as far as how they work with medical students. Maybe your last resident let you go in the room first and then pend orders, and this one just has you shadow, or they come in the room 2 minutes after you started interviewing the patient and totally take over the interview. That can be frustrating but don’t sweat it. It’s not about you.

They will also have different styles when it comes to patients and their workups. For example, many residents have a physical exam maneuver or two that they love to use. I had a resident that asked an elderly back pain patient to get out of bed and stand on heels & toes (an important strength test that is often rushed through in favor of having them stay laying down and “push down on the gas pedal” – I’m sure some of you know what I’m talking about)… few hours later, we had another elderly patient with back pain. I made sure to do that exact maneuver and report the results when presenting. Little details like that will show you’re paying attention and trying to get better.

8. Show up early
Show up at least 15 minutes early to every shift ready to go. If you’re on a rotation where medical students start shifts at the same time as residents, pay attention to when the residents arrive. At one of my rotations the residents always started seeing patients about 15 minutes before their official shift start time, so I started arriving at least 20 minutes early. This does not go unnoticed! Also, be ready to go as soon as you arrive. If your shift starts at 12 and you get there at 11:30 thinking you’re gonna set your bag down and go buy coffee, but your resident spots you and tells you to see the patient in room 20, you forget the dang coffee and go see that patient no questions asked!

You might have a slow shift where the resident says “hey it looks like things are slowing down, you should take off”. There’s no need to argue or pretend like you want to stay forever. A simple “is there anything else I can help you with” is cool, then take advantage of the early release.

9. Be yourself
Duh, right? But here’s my point. The “3 AM” test is real. If you’re not familiar, this refers to how residents/attendings assess whether they could tolerate being stuck with someone on a dull overnight shift at 3 AM with nothing to do. If you don’t pass their “3 AM” test, (i.e. they don’t find you friendly/personable/interesting) they’re less likely to rank you highly. This means when you and your resident aren’t working on something, have normal conversations with them. Ask them how their weekend was, etc. Sounds silly, but just be a normal person, haha.

10. Work your ass off
You get what, 16 or so shifts on a rotation to show them what you’ve got? Don’t half-ass a single shift.

Strong work. 3i seems excessive, 3ii is good. Attendings love it when you ditch the paper crutch. From my experience, #5 and 6 are so critical to success and oft neglected. Everyone hates the complainer--word spreads amongst the residents, whos fun to be around and whos not. It's really nice of you to do this. Thanks for paying it forward.
 
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11) Give us some F'in space! There is nothing I hate more than having a medical student who is literally over my shoulder every second while I am charting or on the phone. Stay close by sure, but 5 or 10 feet is fine, not 5 or 10 inches. Believe it or not I've had multiple students literally stand within six inches of me while I chart. Also pro tip- if you're a close stander/talker dental hygiene is a must, halitosis is not a redeeming factor.

Otherwise all the rest of the stuff is spot on. Above all be friendly, be yourself, have a positive attitude and be willing to get involved. I don't care if you can quote the PERC criteria or give me a ten point ddx for upper abdominal pain, I just want someone who I can BS with during downtime and who is willing and at least partially able to help me out with stuff during the shift. As an MS4 thats literally all you need, no one expects you to be an EM badass, you won't be expected to be one as an intern either, just be on time and eager to learn.

ETA- As GF said- 5/6 are very important, and possibly the hardest things on this list to do, but at least try your best. Also learn to present without paper, there isn't time to write everything down as a resident and it will likely cause you to give a longer presentation.
 
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A lot of these things are what it takes to make a great rotator but honestly I think #5 is what takes students to the next level. There are few things that students can really do that expedite and improve patient care on a regular basis but this is one.
 
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This is spectacular advice. I'd also say the showing up early is a must. It looks awesome when a student comes in, sees the new person that was being roomed while the residents were checking out, and can give a good presentation. It is very, very helpful, and is definitely noticed.

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Not an EM doc but get lots of presentations from trainees in the ER (and elsewhere). I strongly recommend learning to present without notes. Attendings can’t help but feel a little pain when the sheet comes out. Start by only looking down for vitals and labs, then try not to look down, then ditch the sheet.
 
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I have no issues with a sheet of paper as an EP. I want you to be accurate, honest and truthful as my #1 priority and if a piece a paper helps with that, I'm all game. Obviously not reading word for word from the paper but quick references is totally fine .

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I have no issues with a sheet of paper as an EP. I want you to be accurate, honest and truthful as my #1 priority and if a piece a paper helps with that, I'm all game. Obviously not reading word for word from the paper but quick references is totally fine .

Sent from my Pixel 2 using Tapatalk

I am not currently core residency faculty, but I have students rotate through and I agree with this. The first time I work with a student, I want to be convinced that they are performing a correct assessment (at the MS-IV level). If in your first few presentations you are leaving critical information out, I am going to assume that it was either because you are not doing an appropriate H&P, or do not recognize the significance of the issue. Generally speaking, that is not good. On the other hand, if you have had good presentations with notes for awhile, and then switch to no-notes and leave out something important, I am going to assume that you obtained the information but simply forgot to mention the fact. That doesn't bother me because I know that it is something that will improve with practice.

So you definitely want to work towards going without notes, but first you want to prove to the residents/faculty that you are competent (for a medical student.)

More generally, first impressions are important with respect to personality and work-ethic. Early on, I want to know you are competent and safe. With a senior resident, I would expect him/her to be aware when maybe that abdominal pain doesn't need a CT. As a beginning medical student, don't try and wow me with your knowledge of EM. In the same patient, I might give the senior resident a "gold star" for realizing the patient doesn't need imaging/testing, but if you recommend the same thing as a student I will assume you don't know the basics.
 
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[QUOTE="Vandalia, post: 19868076, member: 599406" In the same patient, I might give the senior resident a "gold star" for realizing the patient doesn't need imaging/testing, but if you recommend the same thing as a student I will assume you don't know the basics.[/QUOTE]
So basically you need to master the rules before you can claim to know the exceptions.
 
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Hey all – I have no idea if this will be helpful or not, but here goes. I created a separate sdn account in case this comes across the wrong way. I do not want this to come across as bragging—I apologize if it does. I instead want to provide something that might be helpful to other medical students trying to figure out a way to match into this increasingly competitive specialty.

First off – SLOEs (Standardized Letters of Evaluation) are extremely important. Ask anyone who has gone through the application process, and they’ll tell you that SLOEs will make or break your application. Also this (Council of Emergency Medicine Residency Directors' standardized letter of recommendation: the program director's perspective, search pubmed id: 25039553) and this (Factors Affecting Candidate Placement on an Emergency Medicine Residency Program’s Rank Order List, search pubmed id: PMC3555575). Sorry I can't post links because this is a new account.

Second, my qualifications – I was a relatively average medical student in terms of Step scores, clinical grades, and other factors. I did two EM rotations (a home and an away). Both were at fairly strong programs and I received “Top 10” SLOEs from both. There’s no way to know for certain what’s on your own SLOE, but I was told by interviewers while on the residency interview trail that both of my SLOEs were top 10, and within the comments on one of them it noted that I was among the best students to have rotated. As we all know, a large component of your evaluations just comes down to the luck of who’s evaluating you. So one could argue that maybe I was just an average EM student who happened to get lucky with easy evaluators. I can’t prove you wrong. Nonetheless, I’ll share my approach to the rotations and maybe it will help.

Alright let’s get down to business. Because I was such an average student I knew I’d have to work very hard to do well on my SLOEs. Here are my tips for others like me:

1. Keep a positive, friendly attitude
This cannot be overemphasized. It’s really hard for them to assess your knowledge on an 8/10/12 hour shift, but it’s easy for them to see how you behave. Be considerate. Don’t eat the last donut. Try not to sit at someone’s workstation. If your shift is busy, don’t complain about the work. In fact, try not to complain about anything (use your judgment – obviously things like abuse, unethical practice, etc. need to be brought up!) I witnessed other students speak negatively about patients and nurses. Don’t do that ever. Don’t jump to the conclusion that a patient is faking their pain and then present the patient like they’re a jerk. Give them the benefit of the doubt and then say in your assessment that you think the clinical picture is inconsistent and the patient may be malingering because x,y,z.

Be enthusiastic about learning opportunities. If your shift is over and you’re exhausted and a resident says “oh hey we’re about to put in a central line on this guy, want to help?” you should respond “yeah!” unless you have to pick up your grandma at the airport or something.

2. Listen to podcasts
Such as emclerkship, or embasic, there are several out there. I listened to emclerkship the most because it seemed the most tailored to medical students. Listen in your car or while you’re exercising.

3. Create a cheat sheet
It’s hard to interview a patient, examine them, collect your thoughts, and come up with a plan all in 10-15 minutes, then give a coherent and brief presentation to the resident/attending. Some of my classmates could do this without taking notes or referring to guidelines. I had to rely on what I called my “cheat sheets”. There were two of them:

i) Cheat sheet #1: A double sided piece of paper which had on one side a bunch of common presenting complaints and their major considerations, common workups, and treatments. Think of these as little “workup consults” to refer to when thinking about a chief complaint. For example, here’s what I have written for priapism:

“PRIAPISM: N/A/V at 12 o'clock, urethra at 6 o'clock
Painful? (low flow, ischemic) vs not painful? (high flow, non-ischemic)
-Ischemic: plan for bedside detumescence, caused by SCD, drugs
-Non-ischemic: Plan for Urology cs, caused by trauma, AV malf, mass
Obtain 19g & 21g needles, syringes, gauze, sterile drape, NS, chlorhex
Perform penile nerve block
Aspirate w 19g at 3 or 9 o'clock, irrigate w 21g at more proximal point
Inject 0.25ml of 1mg/ml phenylephrine q10 min”

I had this for chest pain, abdominal pain, headache, syncope, AMS, vertigo, asthma, COPD, CHF, head/neck/leg injury, lacerations, fractures, burns, vaginal bleeding, torsion & other testicular complaints, epistaxis, sickle cell, dental pain, DKA, hyperkalemia, hyponatremia, psych, sepsis, and on and on… (I have my document in Excel and the font is very small but it’s easy to fit all these on one side of the paper)

I wrote a lot of these little “workup consults” using the podcasts (tip #2 above). As each rotation progressed I would make additions or modifications based on what I learned from residents. There were multiple times when I looked like a freaking genius but really all I had done was refer to my cheat sheet before seeing each patient. Like diagnosing and treating a periapical abscess (thanks EMclerkship! check out the episode on Dental Pain).

On the other side were a few different clinical decision tools and their point systems (e.g. PERC, HEART, Wells, CURB-65, CHESS, Canadian head CT, etc.) as well as some differentials for complaints that have a wide differential (e.g. AMS, abdominal pain). These weren’t used a whole lot but it was still helpful to refer to them from time to time.​

ii) Cheat sheet #2: This was just an H&P note-taking sheet like ones you’ve probably used or seen other students/residents using. I customized my own as follows (the font was very small so I could fit everything): HPI section, with reminders for specific questions to ask patients with chest pain, SOB, AMS, HA, dizziness. A review of systems section with symptoms to ask about depending on the patient’s complaint, organized by system. A PMH/PSH section. Meds/Allergies section. Fam hx/social/smoking/etoh/drugs/other section. Vitals/Phys exam section. Labs/imaging/studies section. Assessment/Plan section. And importantly, a dispo section – should the patient be admitted/discharged/depending on what?

A lot of people are good enough to not use a note-taking sheet like this. I found that I could present without one if needed, but sometimes I’d leave out an important exam finding, or I’d forget to mention the EKG or whatever. I wanted to be thorough. It definitely looks a lot “smoother” if you can just present on the fly without looking down at a sheet of paper. Kudos to those who can do well that way, I just wasn’t good enough.

As I mentioned, I made the font small. I could fit one of these on a half sheet of paper so I was using 1 double sided sheet for 4 patients.​

4. Keep your presentations brief
Unless told otherwise, keep them extremely brief. Yes, my note-taking sheet had a section for family history, but I used it probably like 1% of the time. If it’s not relevant to why the patient is in the ED, don’t bring it up.

When describing pain try to cram a bunch of descriptors into 1 sentence. “Patient reports a sharp 9/10 intermittent non-radiating pain in her RUQ that’s worse after eating and not relieved by motrin.” rather than “patient reports a pain in her RUQ that she says is as bad as 9/10 but sometimes 7/10, that she describes as sharp. It doesn’t radiate. It comes and goes. She feels like it’s worse after eating. She tried taking motrin but had minimal relief.”

Then report the pertinent positives & negatives. I’d usually say something like: “Associated with nausea and 1 episode of NBNB vomiting. She denies fevers, diarrhea, reflux, CP, SOB, etc.” Don’t go on forever with pertinent negatives.

5. Anticipate anticipate anticipate
This was always difficult for me on my clinical rotations. As med students we’re always trying to anticipate the resident’s needs and address them early so that it makes their lives easier. On my EM rotations, I paid close attention to supply needs. When doing an LP/central line/whatever, there are often procedure kits that you’ll want to grab. But these don’t contain everything. You’ll need to get gowns/gloves etc, probably an extra syringe & needle, maybe some extra sterile towels or whatever. The first time you do a procedure with a resident take note of everything they needed to get from the supply closet. Next time you need to do that procedure, grab everything ahead of time.

There are other ways you can anticipate what’s needed. You see a patient with a vaginal complaint? Grab all the items you need for a pelvic exam and put them in the room. Go find your resident and present. See the patient together, boom everything is there waiting for you to do the exam. You see a patient with RUQ pain that you think needs an U/S? Finish the interview, grab the ultrasound if it’s available, put it in the patient’s room. Go find your resident and present. Mention that the u/s is in the room ready for whenever they’d like to do it, and you’ve already entered the patient’s information into the machine.

6. Follow your patients
Easier said than done. You order some labs or some imaging, then move on to the next patient and forget about everything. Always be checking the test results of patients you’ve seen and update the resident. Most of the time he/she has already seen the result but sometimes you’ll be the first person to notice an abnormality and it’s nice to give the resident a heads up. Don’t just report the results, though. Report the results and follow it with “so would you think it’d be a good idea to treat with x?” Have a plan based on what test results show.

Check in on your patients. One of the better things you can report to a resident is “hey I checked in on our migraine girl in room 8 and her pain is down to a 2/10, says she’s OK going home”. A good time to check in on old patients is right after you’ve presented a new patient, before you pick up another one. If you feel like it you can mention “hey I’m just gonna go check in on so-and-so in room 12.”

7. Be flexible
Some programs have you work with the same resident the whole month, but most will have you working with a different resident/attending almost every shift. Each may take a completely different approach from the next as far as how they work with medical students. Maybe your last resident let you go in the room first and then pend orders, and this one just has you shadow, or they come in the room 2 minutes after you started interviewing the patient and totally take over the interview. That can be frustrating but don’t sweat it. It’s not about you.

They will also have different styles when it comes to patients and their workups. For example, many residents have a physical exam maneuver or two that they love to use. I had a resident that asked an elderly back pain patient to get out of bed and stand on heels & toes (an important strength test that is often rushed through in favor of having them stay laying down and “push down on the gas pedal” – I’m sure some of you know what I’m talking about)… few hours later, we had another elderly patient with back pain. I made sure to do that exact maneuver and report the results when presenting. Little details like that will show you’re paying attention and trying to get better.

8. Show up early
Show up at least 15 minutes early to every shift ready to go. If you’re on a rotation where medical students start shifts at the same time as residents, pay attention to when the residents arrive. At one of my rotations the residents always started seeing patients about 15 minutes before their official shift start time, so I started arriving at least 20 minutes early. This does not go unnoticed! Also, be ready to go as soon as you arrive. If your shift starts at 12 and you get there at 11:30 thinking you’re gonna set your bag down and go buy coffee, but your resident spots you and tells you to see the patient in room 20, you forget the dang coffee and go see that patient no questions asked!

You might have a slow shift where the resident says “hey it looks like things are slowing down, you should take off”. There’s no need to argue or pretend like you want to stay forever. A simple “is there anything else I can help you with” is cool, then take advantage of the early release.

9. Be yourself
Duh, right? But here’s my point. The “3 AM” test is real. If you’re not familiar, this refers to how residents/attendings assess whether they could tolerate being stuck with someone on a dull overnight shift at 3 AM with nothing to do. If you don’t pass their “3 AM” test, (i.e. they don’t find you friendly/personable/interesting) they’re less likely to rank you highly. This means when you and your resident aren’t working on something, have normal conversations with them. Ask them how their weekend was, etc. Sounds silly, but just be a normal person, haha.

10. Work your ass off
You get what, 16 or so shifts on a rotation to show them what you’ve got? Don’t half-ass a single shift.

You don't happen to have your cheat sheet saved on a file do you? This would be really helpful to have rather than making my own from scratch as I start my clerkship! I can PM you if you'd like, but thanks ahead of time if you can!
 
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