some more thoughts on third and fourth years:
GENERAL RULES:
1) as stated earlier, never make your co-student look bad. i've had some med students on my service that have pimped other students. this will drop their grade dramatically. always work as a team, and don't be cut-throat. we (housestaff, fellows) can see this. it's pretty obvious.
2) when i was a resident, one of my favorite students would ALWAYS be doing scut for us, WITHOUT us asking. he would listen during work rounds, make a list of things i told my interns to do, then he would go and run off and do them!! amazing. also, he would get all the charts as we rounded.
3) know everything about the patient. another one of my favorite students was with me on the GI consult service (i am a GI fellow). we had 25 patients on the service. he would go and see 10-12 consults with me per day, and knew EACH AND EVERY PATIENT as well as i did. that kid walked on water.
both of them are now doing their residency at Harvard.
4) bring in articles, and teach the intern/resident about cool stuff. for example, if a patient with a rare disorder (say, polyarteritis nodosa, or celiac sprue) was admitted, bring in articles, teach the housestaff during rounds, so they can look good during attending rounds. you will be rewarded by the housestaff giving you a good evaluation, and telling the attending how great you are.
a few words about grading:
the housestaff have the greatest input into your grade. in most institutions, the intern and resident grade the student, and the attending will meet with them, and discuss the student's performance. so having the housestaff on your side is a big bonus.
5) don't show off.
6) for internal medicine, be able to come up with an assessment and plan. most students are great at the history and physical; what impresses me most about students are the ones that can come up with a well-thought out differential diagnosis, and both a diagnostic and therapeutic treatment plan by integrating pertinent history and physical details.
for example, a patient presents with nausea and vomiting. the history is that the nausea and vomiting occur 30 minutes after food ingestion for three months, and the patient also complains of epigastric pain. No fevers, chills, no diarrhea, no pain radiation, no alcohol abuse
differential diagnosis should be stratified into:
most likely, less likely, and why, and the third group is "cannot miss cuz it will kill patient"
so for this patient:
most likely are:
biliary colic, cholecystitis, gastroparesis, gastric outlet obstruction.
ulcers
less likely are gastroenteritis, bowel obstruction, appendicitis, acute pancreatitis
will kill patient are:
mesenteric ischemia, bowel obstruction
diagnostic plan and why:
cbc - look for infection and inflammation
chem 7 - anion gap for ischemia
lft - look for cholelithiasis and gallstone pancreatitis (along with amylase, lipase)
either CT abd or abd obstruction series with ruq u/s to exclude obstruction and biliary source.
if all else negative, remaining diagnosis is gastroparesis vs ulcers: gets upper endoscopy and gastric emptying study.
not that all students should know this at time of admission or consult, but by doing a quick lit search overnight, can find a good review article by the AGA on w/u of nausea and vomiting.
j
