Where should a fourth year student be in terms of patient management?

[socomtoaster]

Hello everyone,

I had the opportunity to rotate with an outside school in the field of medicine I was hoping to apply to this month. Unfortunately, during the time, the attendings felt I was either not a match with their program, or that I was behind my peers in medical knowledge and ability to manage patients. I felt like I was often trying to 'guess' what the attending was trying to do, and trying my best to read up on diagnostic tests to prepare for these discussions, but I always felt blindsided by the end. I have a general sense of what patient management should entail, but I know I'm probably not ready to independently take on the full responsibility of patients yet. Is this something that is generally expected of incoming fourth year students? At my institution, I had some minor involvement in clinical decision making during the third year, but never really generated a fleshed out plan. Now that I am expected to do this, I feel like I am learning that skill fairly quickly, but it certainly wasn't enough to impress my attendings. I want to learn this, but now I feel like I may be behind on this, and I'm not sure how to move forward with it. What is expected of you as fourth year students on rotation?

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[GoSpursGo]

It's very institution, specialty, and attending dependent.

In general, I'd like 4th year students to start formulating their own assessments and plans, and while all the details might not be perfectly right or fully fleshed out I'd like to see that they're at least in the ballpark. Of course I don't expect that you're going to be able to "independently take full responsibility," but you've got to be at least able to try and do the exercise and get part of the way there. Schools that shield students from needing to formulate an assessment and plan, or that don't take the time to do so, really do a disservice IMO. Nothing is a bigger red flag to me than when a student just presents a bunch of data and then looks to me and says "so what should we do?" It sounds to me like your school probably let you skate by on doing just that throughout 3rd year, and nobody thought to prepare you for this change in mindset when you did an audition. The goal for every sub-I is to be "operating on the level of an intern," and if your first attempt on doing this exercise was in front of these attendings at your audition rotation then unfortunately I'm not surprised it didn't go well.

This is the risk with doing an "audition" rotation, you're invariably going to get compared against the home students who will know the EMR, and know the attendings and expectations. It is also why many of the more competitive specialties "expect" audition rotations, because you're going to get judged relative to other visiting students and not just get effusive positive feedback to shield their students' egos. My advice to students reading this is that, even if you can skate by in your 3rd year without bothering to make your own A/P, you should at least try. It will pay off in your 4th year.

 

[socomtoaster]

It's very institution, specialty, and attending dependent.

In general, I'd like 4th year students to start formulating their own assessments and plans, and while all the details might not be perfectly right or fully fleshed out I'd like to see that they're at least in the ballpark. Of course I don't expect that you're going to be able to "independently take full responsibility," but you've got to be at least able to try and do the exercise and get part of the way there. Schools that shield students from needing to formulate an assessment and plan, or that don't take the time to do so, really do a disservice IMO. Nothing is a bigger red flag to me than when a student just presents a bunch of data and then looks to me and says "so what should we do?" It sounds to me like your school probably let you skate by on doing just that throughout 3rd year, and nobody thought to prepare you for this change in mindset when you did an audition. The goal for every sub-I is to be "operating on the level of an intern," and if your first attempt on doing this exercise was in front of these attendings at your audition rotation then unfortunately I'm not surprised it didn't go well.

This is the risk with doing an "audition" rotation, you're invariably going to get compared against the home students who will know the EMR, and know the attendings and expectations. It is also why many of the more competitive specialties "expect" audition rotations, because you're going to get judged relative to other visiting students and not just get effusive positive feedback to shield their students' egos. My advice to students reading this is that, even if you can skate by in your 3rd year without bothering to make your own A/P, you should at least try. It will pay off in your 4th year.

I appreciate that point. I think there may have been some of that 'shielding' going on during my third year, looking back, and I'm hopeful to improve on it, but I do feel personally hurt by it. I guess I will have to pursue this with more vigor then some, but I should look into how I can integrate that for our upcoming students. I don't want to be viewed at not being capable. I want to be capable.

 

[GoSpursGo]

I appreciate that point. I think there may have been some of that 'shielding' going on during my third year, looking back, and I'm hopeful to improve on it, but I do feel personally hurt by it. I guess I will have to pursue this with more vigor then some, but I should look into how I can integrate that for our upcoming students. I don't want to be viewed at not being capable. I want to be capable.

FWIW, chances are that you ARE capable, or at least you could be. You've got a full year ahead of you before you actually have to care for patients as an intern. Use this time to get better.

 

[operaman]

You can definitely learn to do this, but it takes some time and focused effort. Agree that your school may have hosed you a bit by letting you slide by without having to do more plan formulation as a third year.

Generally speaking, I advise students to focus their learning of management on the most common conditions first. In my field of ENT, that's things like chronic sinusitis, hearing loss, tonsil and adenoid disease, H&N squamous cell carcinoma, etc. Learn the common stuff really well first -- I'd be shocked if you did an ENT rotation and didn't encounter all of those conditions multiple times. Memorizing the basic mgmt for those is not that hard - you could memorize the cancer staging in a single weekend and tonsillectomy indications in an afternoon. Then you're pretty much set when you're rotation through a peds ENT clinic because half the new patients will be kids sent for tonsil stuff and you'll know whether they need surgery or not without having to do much extra reading. If you're wrong, it's probably an unusual case and will be a topic worth a little discussion anyhow. If you know cancer staging cold, you can see a new cancer patient and quickly check the NCCN guidelines before presenting and make a pretty decent evidence-based plan.

Same basic idea applies accross specialties - figure out what's super common and learn the management for those things first. It's tough because we often focus on the rare and interesting pathologies in training, but the day to day of clinical practice is the routine stuff. You need to know all of it of course, but you'll want to start with the highest yield topics and slowly branch out from there.

 

[Goro]

You can definitely learn to do this, but it takes some time and focused effort. Agree that your school may have hosed you a bit by letting you slide by without having to do more plan formulation as a third year.

Generally speaking, I advise students to focus their learning of management on the most common conditions first. In my field of ENT, that's things like chronic sinusitis, hearing loss, tonsil and adenoid disease, H&N squamous cell carcinoma, etc. Learn the common stuff really well first -- I'd be shocked if you did an ENT rotation and didn't encounter all of those conditions multiple times. Memorizing the basic mgmt for those is not that hard - you could memorize the cancer staging in a single weekend and tonsillectomy indications in an afternoon. Then you're pretty much set when you're rotation through a peds ENT clinic because half the new patients will be kids sent for tonsil stuff and you'll know whether they need surgery or not without having to do much extra reading. If you're wrong, it's probably an unusual case and will be a topic worth a little discussion anyhow. If you know cancer staging cold, you can see a new cancer patient and quickly check the NCCN guidelines before presenting and make a pretty decent evidence-based plan.

Same basic idea applies accross specialties - figure out what's super common and learn the management for those things first. It's tough because we often focus on the rare and interesting pathologies in training, but the day to day of clinical practice is the routine stuff. You need to know all of it of course, but you'll want to start with the highest yield topics and slowly branch out from there.

The head of our Clinical Education Dep't has only one question for 4th students: "what's your Dx and your Tx plan"?

 

[mrbreakfast]

It's highly program dependent. The difference between the "average" medical student at one institution compared to another can be dramatic.

I want to know, in increasing order of difficulty:
1) Does this patient need to stay in the hospital, or can we discharge them? (i.e., sick or not sick)
2) What do you want to do for them right now?
3) WHY do you want to do those things?
4) What do you think is wrong with the patient?

I'm an academic neurohospitalist. We see all sorts of stuff. I don't expect my medical students to necessarily know what the entire differential is, nor how they should specifically treat something they've never heard of. I care more about their thought process, and its development and growth, than the answers being "book."

 

[Redpancreas]

I’m sorry to hear about your experience; that must have been disappointing. Unfortunately, this is something that can happen during an external audition rotation, and you’re not the first, nor will you be the last, to experience it. While you might not be matching there or getting a strong letter of recommendation, receiving honest feedback can be valuable.

I would suggest arranging a brief meeting with the attendings to see if they can provide you with any actionable feedback to help you improve for future rotations. That said, don’t be too hard on yourself. Much of their impression could tied to you being outside your comfort zone.

Regarding where a fourth-year student should be, it varies. It’s important to keep in mind that in a 2 or so years, you’ll need to start making semi-independent decisions on diagnosing and treating patients. Every time a decision is made during rounds, think about what you would do if you were the resident, why, and compare that to what actually happens. Remember, you’re training now to be a resident, not a student and when you’re a resident you’re training to be an attending.

I agree with the above advice. Keeping those questions in mind will help you focus on gathering the right data and taking the right actions to manage patients. There will always be new diseases and situations to learn more about, and that comes with experience.

Best of luck!

 

[voxveritatisetlucis]

Depends on the school and the specialty. in general most community hospitals are trash for teaching students since the attendings either don’t want the liability or don’t want to be slowed down. Also for example at my school OBGYN is basically just shadowing so if you apply to that from my school then it would be very hard on a subi or visiting rotation to actually know what you should be doing when it comes to managing patients and all that

 

[Lost in Translation]

Hello everyone,

I had the opportunity to rotate with an outside school in the field of medicine I was hoping to apply to this month. Unfortunately, during the time, the attendings felt I was either not a match with their program, or that I was behind my peers in medical knowledge and ability to manage patients. I felt like I was often trying to 'guess' what the attending was trying to do, and trying my best to read up on diagnostic tests to prepare for these discussions, but I always felt blindsided by the end. I have a general sense of what patient management should entail, but I know I'm probably not ready to independently take on the full responsibility of patients yet. Is this something that is generally expected of incoming fourth year students? At my institution, I had some minor involvement in clinical decision making during the third year, but never really generated a fleshed out plan. Now that I am expected to do this, I feel like I am learning that skill fairly quickly, but it certainly wasn't enough to impress my attendings. I want to learn this, but now I feel like I may be behind on this, and I'm not sure how to move forward with it. What is expected of you as fourth year students on rotation?

What field? Because if it’s something like DRads the expectation is different than Gen Surg.

Everyone else has provided very good advice on how you can start to formulate plans become an independent thinker. I’ll add in that if you’re going into a field that carries a sizeable inpatient census, start practicing on learning something about every patient on the list and not just the 3-4 you’re assigned/dedicated to. That doesn’t mean on rounds you should interrupt that patient’s primary student when they’re presenting, but you would be able to fill in information when needed i.e. if the attending or resident asks another student for X info about a lab or plan for a patient and that student can’t answer and the question gets opened up to the group you can then chime in with you know and that shows you’re engaged and taking more responsibility than would be expected of a med student. You’re going to be a resident soon and when that time comes you will be responsible for every patient on the list so no better time than the present to get used to doing that.

 

[Med Ed]

Terrified.