Clinical Rotation Advice
As some medical students are starting to be allowed back to their clinical rotations as COVID-19 cases rise more slowly, I want to build off of my previous post, Third Year Advice. In this previous post, I covered some general topics and shared how I studied during my third year, and here I’d like to build off of that and offer some more specific advice based on questions I’ve been asked by rising third years.
What does “a day in the life” of a third year medical student look like?
The answer to this definitely depends largely on two factors: the specialty you’re assigned to, and the resident team you’re working with. However, there are a few common themes that I can briefly touch on here.
In general, you will be assigned to “round” on a patient on your own each morning, often before your resident sees them. This task is very intimidating at first, but it quickly became one of my favorite parts of the day because it’s one of your main opportunities to talk one-on-one with your patient. “Rounding” on your patient will generally start with reading through their medical chart: looking for overnight events, reading any new nursing or physician notes, and getting an updated list of their labs and medications. I liked to do this “chart checking” before I physically saw my patient, just in case I needed to ask the patient or their nurse about something I read. Next you’ll go to your patient’s room and do a quick physical exam and verbally check in with them. What you ask them and if you do anything else at this time will depend on your residents and the specialty. For example, on a surgery rotation your physical exam might include taking down dressings and examining incisions. Some general things that are always good to ask the patient are: how their symptoms are progressing compared to the previous day, how their various treatments are working or controlling their symptoms, if they’re eating and drinking normally, bowel movement progress, and a quick review of systems.
Whenever I am finishing up my encounter with my patients, I like to reiterate my role on the team to them so they’re not confused as to why they’ll likely be asked the same questions I just asked by 1-2 more people. Generally I’ll say something along these lines:
“Thank you again for letting me wake you and check in with you. Like I said, I’m Monica, one of the medical students working with your Internal Medicine team. I’m going to talk with the resident doctor about what we talked about, and they might also come in and ask you some of the same questions and do their own exam since I’m still learning. Then later this afternoon, they’ll be a big group of us including the attending doctor in charge of the whole team, and we’ll give you the final plans and updates for the day.”
If you’re ever unsure if you should do or ask something when you see your patient, always always check with your resident first! They will appreciate over-communication than you making an assumption that might lead to extra work for them or an unnecessary inconvenience for the patient.
After you’ve done your “round” on your patient by yourself, you’ll generally meet up with your resident at that time and discuss what you found and what the next steps are for your patient. Then you’ll do “rounds” with the entire resident team and the attending physician. These “rounds” will vary in length. Rounding as a team includes some type of presentation to the attending about each patient and making clinical decisions/plans for the day, and then physically checking in with the patient as a large group. Team rounds like this are often where a lot of our learning as medical students takes place. As I mentioned in my previous post, definitely try to write things down about each patient your team is following, even if the patient isn’t assigned to you. Ask your resident for a copy of the patient list so you can keep up easier, just be careful with the list and be sure you place it in the appropriate shredding bins when you’re finished since it might include identifying information.
Giving a good patient presentation is one of the most important skills you’ll work on during third year.
Something that was repeatedly told to me during third year is that it is the year when us medical students should learn to be the best data gatherers and history takers we can be. We may not always know what the next steps will be for our patients, but we should always know the patient’s history and hospital course very well. To be honest, I still get nervous giving the attending physician my patient presentation, but I have definitely greatly improved from the beginning to end of my third year.
What is a patient presentation? … It is the verbal summary of what brought the patient to the hospital, the patient’s history (medical, social, surgical, etc), as well as objective findings. The general way people organize presentations tends to be “SOAP: subjective, objective, assessment & plan”, and in your third year your main objective is to get really good at presenting the subjective and objective, and then by the end of third year be able to give some reasoning behind your assessment and plan. I will say, presentations will vary a lot between the specialties so you’ll have to rely on your residents and trial and error for guidance. In general, it’s better to start with covering more detail than leaving anything out, and it’s better to start with a more “formal” presentation rather than trying to copy the residents’ style as they might be more informal than we’re able to be at our level.
I personally don’t think it’s possible to ever feel like you’ve “mastered” the patient presentation, but practice and repetition is just the best way to cultivate this skill. I would suggest writing everything down at first to be sure you don’t miss any parts of the presentation, but every one is different in how they prepare. As a new fourth year medical student, patient presentations are one of the most important skills that I will continue to actively work on, because there’s no such thing as too much practice with them.
How to be a good team member
In general, I think the best mindset to have is to treat medical school rotations like they’re your job. By this I mean to act as professionally as you would if you were working, and always try to be active and working on something even if it’s just studying to yourself while your residents are busy. In my previous jobs, my mindset was that if I was on the clock, I should be trying to be active and working, trying to find things to do. I went into third year with that same mindset and earned good evaluations and had great working relationships with the residents in charge of me.
If you can make your resident’s day go smoother, even if it’s just with small tasks not necessarily directly related to patient care, do your part and help them out. Keep track of the “to-do” list for each patient, and if there are tasks you feel comfortable helping with, offer that help to the team. Making phone calls to find out patient medications, calling to try to obtain patient medical records from outside facilities, running back to the patient room to ask them a quick question we forgot on rounds, etc. can all add up to help you make a significant contribution to your resident team.
One skill that some students have to learn during third year, especially if they have limited previous clinical experience, is that there are good and bad times to ask questions. I am grateful for my previous scribing experience, because that definitely taught me some of the cues to look for and gave me a general sense of good and bad times to speak up. So just in general, be cognizant of your residents’ body language, peak at what they’re working on if they’re on the computer and don’t interrupt if it seems complicated, etc.
That being said, we’re students, so it’s inevitable that we’ll misread a situation and ask questions at the wrong time, so try not to take it personally if you’re temporarily dismissed or they don’t have time to help with whatever you’re asking about. You never know what an individual is going through in their own life, and the stress of medical school and residency I think pushes most of us not to be our best selves 24/7.
Navigating amongst the hierarchy of medicine
I personally had no idea how important and engrained the hierarchy is within medicine amongst students, residents, and attendings. It makes sense absolutely, because as you go up the hierarchy of docs the more responsibility there is, but there are a few pieces of advice that I had to learn from the residents since I didn’t have upperclassmen to share.
Report new patient information to the intern or resident that is directly above you or the resident that is taking care of the patient. Even if you get excited because some result is back that the whole team was waiting for, tell the intern or lower level resident first not the senior resident or attending. It’s just one of those unspoken things that I’m grateful a resident pointed out to me.
I’ll repeat this because it’s just so important: try not to take anything personally. I didn’t always succeed at this, I definitely shed a few tears when I got a bad evaluation or when I had been “pimped” on several questions in a row that I didn’t know in front of a group. Just keep your head up, stay professional, and use everything as motivation to push you forward to continue studying and improving.
That being said though, know how to report mistreatment at your school if it were to occur. If you have a learning opportunity taken from you, that is typically where a line is drawn that things are crossing into mistreatment rather than an educational style. We are extremely fortunate at UNLV and are treated exceptionally well by the majority of the people we interact with, and I’m so grateful I am able to rotate at a teaching hospital where students are truly expected and integrated into most specialties.
Some surprising things about third year rotations
One of the things that surprised me the most was how receptive patients are to sharing with us students some of their most personal details during such vulnerable moments in their lives. I expected more patients to be unwilling to talk to a student because they were in pain or didn’t want to repeat themselves, but was happily surprised that patients generally liked talking with me. This aspect just reiterated to me how privileged we are to be on this path and to be working to earn the trust of our patients when we’re the ones making decisions someday.
Another surprising common thing in medicine is that patients will change their recount of the events leading up to their hospitalization each time they give their history. Part of this is they tend to remember more details as they’re repeatedly asked, and part of it I think is just human nature as we change the way we retell stories. Whatever the reason, it really threw me off as a new third year when the patient would tell the resident new or different details, and I was nervous at first they would assume I didn’t ask or that I was remembering incorrectly. However, residents and attendings all know that this happens often, so try not to be too alarmed by this. All we can do is report what the patient tells us.
The last thing I’ll say I was surprised about was how unique each specialty really is, and at how the lines are drawn between them. As a first generation college student who had never really talked to physicians outside of work, I was just ignorant to all the details of specialties within medicine. I always knew the most about emergency medicine after working with ER docs for two and a half years, but kind of expected a similar experience regardless of specialty. I was definitely wrong, as I’ve mentioned, your experience is extremely variable depending on what specialty you’re working with. I was surprised that on occasion there was a sense of negativity towards some specialties, but I guess it makes sense that everyone hopes to end up in the specialty they think is the best choice. That being said, my final pieces of advice for this post are this: First of all, be honest about what specialties you’re interested in. And second, if anything negative is said about a specialty you’re interested in just take it in stride and keep in mind that every specialty is not a good fit for every student. My student affairs dean always tells us that we’ll all “find our people” as we navigate through the journey of third and fourth year, and so far he’s not wrong.