A Side of Sweet

Last week, I was on a panel of fourth year medical students that answered questions for the incoming third year class.  They were just starting their rotations and I remember how intimidating it was.  You go from spending all day, every day studying and memorizing to interacting with real human beings.  Here are some practical tips on how to survive third year and maybe even do well!

Here’s the List:

1.  No matter what, act like you are happy to be there.  People really notice this.  There are definitely going to be days, or entire rotations, that you feel will never end.  However, you still have to be there, so why not feign enthusiasm?  Being able to master this skill is a great way to boost your clinical grades without doing extra work outside of school reading or studying.

2.  Pimping (usually) is not meant to crush your soul.  Often, attendings use it to start a teaching topic.  Don’t let it ruin your day if you get a few questions wrong.  I’ve found a handy way to prevent pimping is to ask a lot of questions.  Another handy skill is redirecting.  If you can tell an attending is about to ask you a stream of questions, you can often change the tide by saying something like, “Oh, that reminds me of a question I wanted to ask you _____”  Ask a question about the current patient and why something with their care is done that way.  For example, you could ask about prognosis or for clarification of a physical exam technique.  You have then started a discussion/opened the door for a teaching topic/showed that you care – and the attending doesn’t have to pimp you!

3.  Keep a list of things you want to learn about.  Inevitably, someone will say, “Ok, so we have a few minutes free.  What would you like to learn about?”  Usually, it’s hard to come up with something on the spot, so writing a few things down ahead of time to keep in your white coat will serve you well.  Here are some examples:

    Surgery: anatomy of hernias, intake orders for a patient, fluids and electrolytes, triaging a trauma
    Medicine: fluids and electrolytes, mechanisms and uses of antibiotics, criteria for sepsis, breaking bad news to families, recognition/tx of substance overdose or withdrawal
   Pediatrics: treatment of DKA and the two bag system, uses of antibiotics, dehydration, newborn screening, developmental milestones, differential/history/tx for a headache
    OB/Gyn: women’s health screening guidelines, screenings in OB visits, criteria and treatment of gestational diabetes, workup for third trimester bleeding, workup for infertility, presentation of torch infections, birth defects from drugs or substances
     Psych: differences between atypical antipsychotic preparations, personality disorders, screening for and treatment of substance abuse, different types of counseling/therapy

4.  Read the guidelines.  Most professional organizations come up with recommendations for patient care.  This can range from treatment of otitis media in your pediatrics rotation to pelvic and breast exams in OB/Gyn.  Find the summary and skim it – it will take 10-20 minutes.  Discuss the recommendations with your supervising physician and you will become better at evidenced based medicine and impress everyone with your thirst for clinical knowledge.  You can also cite guidelines and decision criteria in the Assessment section of your H&Ps/full write-ups to support your Plan.  For bonus points, you could offer to give the team a 5 minute presentation of what you read – it’s a good refresher for everyone.

5.  Leave when you are excused.  You will not get extra credit for sticking around after your resident tells you to go home.  Often they won’t tell you twice and you will end up being stuck for a very long time.

6.  That being said, Don’t Ask to Be Excused.  A better way to plant the seed that for someone to send you home is to ask, “What can I do to help out?”.  This will convey that you have finished your own work and remind the resident that you exist.

7.  Keep granola bars in your white coat pockets at all times.  This is especially important on surgery, but can work for all rotations.

8.  Find little ways to work exercise into your day.  During the rotations where you don’t have as much time to stay active outside your rotation, stay fit in the hospital!  During my surgery rotation, I made it a goal to take do 20 flights of stairs every day, scattered throughout the day.  By the end, I was faster on my hill workouts than before the rotation started, even though I wasn’t working out every day.

9.  Make up little games to pass the time.  If a surgical case ran long, I would try to contract every muscle in my body individually for 10 seconds starting with my toes.  Weird, right?  Maybe, but no one can tell and you might even improve your core strength!

10.  Invest in a pair of compression socks for your surgical and OB rotations.  Lots of standing is not only uncomfortable, but it can lead to varicose veins.  Many of the attendings, even the men, where compression socks.  You just can’t tell!

11.  Be best friends with your fellow med student.  If you are working closely with another medical student during a rotation, set expectations at the beginning.  Offer to exchange cell phone numbers and tell them that you have their back no matter what.  On rare occasions if one of us was running late, the other would see their patients so they would still be ready for rounds.  You can also let each other know about schedule changes, or when the physicians in charge want to meet with you.  I’ve seen other med students try to make themselves look better by sabotaging their partner.  This does not work.  People will find out and you’ll look like a fool.  It’s also really bad for team moral.

12.  Keep a spare change of clothes at school.  You never know when you are going to end up in clinic instead of the OR.  Always have a back up so you aren’t frantically calling your significant other trying to wrangle some dress pants and a nice shirt.

13.  Sit when you can.  For some reason, my first few months of medical school I thought I needed to stand awkwardly in the exam room while both the doctor and the patient sat.  This added up to at least 8 hours of standing on a typical clinic day.  No one is impressed by standing – they most likely don’t even notice.  Sit whenever you can, whether it is on the little foot stool below the exam table or on a chair next to the patient.

14.  Find little ways to make your life easier.  If you use electronic medical records, make templates to make your H&Ps go quicker.  Have your review of systems and physical exam typed out so you can just add them quickly. If your medical school uses epic, you can actually build them into your EHR as ‘dot phrases’. You can make dot phrases for plans for common conditions, such as ‘supportive care’. In urgent care, I added this to almost every note, talking about how I discussed supportive care for the common cold with families with advice such as avoiding cough syrup and using a dehumidifier.  If you don’t use Epic, try using a google doc for this purpose. This was how I used to do it before our EHR got really good.  It was easy to cut and paste in, and then I could edit the positive and negative findings of the exam.

15.  Be nice to the nurses and mid level providers.  They can make or break you.  They also talk to the docs and word will get around if you are a pissant.

16.  It’s never too early to start thinking about letters of recommendation.  Some people say you should try to get a letter of rec outside of your field – for example, a surgical letter if you are going into medicine, or a medicine letter if you are going into a surgical field.  A good way to figure out who might write a good letter of rec is to look at your Dean’s letter comments.  Someone who writes a glowing review with specific examples of how you did well on the rotation is a great person to ask.  I asked a pediatric urologist to write one for me.  He is a surgeon, but still works with kids – the perfect combination for someone going into pediatrics!

17.  Register for Step 2 Clinical Skills Early.  Spots fill up quick and there are only five places in the US that offer the exam.  I wanted to take it this summer right after a similar exam that my school offers and I barely got a spot.

18.  Budget for Step 2 Exams.  They cost around $1,600.  Seriously.  And don’t even get me started about fourth year interview costs…

That’s all I have.  If you have anything else to add, leave it in the comments section!