The Ultimate Guide to Clinical Rotations (part 1)

TIPS FOR GETTING THE BEST GRADE

If you’ve read a lot of my advice articles before, a lot of this is going to sound familiar. That’s because these are tried and true tips! Even if you’ve read similar things before, I’d recommend reading again (as well as part 2 on mindset and part 3 on away rotations, both dropping later in the week). The more you review, the more likely you are to learn the principles. These are the things I did to get an outstanding (the highest clinical grade at my medical school) on EVERY clinical rotation. Let’s get into it!

First things first: Get to work EARLY EVERY DAY (early, not on time) and never ask to leave early (except in cases of emergency, and then make that clear)

Things to find out at the VERY BEGINNING of each rotation:

  • Who is evaluating you? Will it just be attendings? Will is be residents and attendings? Do you have to give paper evaluations to multiple people over the course of the rotation? Will you have someone new evaluating you once a week?
  • THIS IS CRUCIAL: Find out the expectations your attending and residents have for you at the beginning of each rotation (or every time they switch). Note: different attendings and different residents have different expectations. If you don’t know them, you can’t fulfill them. Unfortunately, if you don’t ask for them, they may NEVER tell you, but they will still grade you against standards you never knew they had.
  • How many patients are you expected to follow on the team? Are you supposed to be writing notes in the computer and signing them over to a resident? Are you supposed to be writing notes and signing them over to the attending? How would they prefer you present patients on rounds (Quick presentations with only new and pertinent information such as abnormal lab values etc, or longer, more detailed presentations, including reporting normal findings and lab values)?
  • Who are you going to be working with? Residents, or directly with the attending? How can you contact them? Do they want you to text them, page them, call them, or just go looking for them? Believe it or not, the answer to this question can vary widely.
  • Are there lectures and conferences you are supposed to be going to as a medical student? Where are they, when are they, and who do you need to tell before you go so no one thinks you’re just roaming the halls?
  • What are the rules regarding COVID? How many people are allowed in each conference room? Are medical students allowed to take care of patients on isolation? It’s important to understand these things to keep yourself safe, and also to avoid slowing the team down.

Develop a system for pre-rounding.

  • For each patient I would look at nursing notes for overnight events, then vitals and ins/outs overnight (and record the ranges), then AM labs (or following up any labs that may have been ordered in the evening), then imaging or other studies from the day before, then I would look at the medication reconciliation (to make sure they were actually getting all the medications that were ordered, confirm that all medications were still indicated, confirm none had fallen off, and to check how often they were needing their PRN, or “as needed” medications such as pain medications and anxiety medications). After looking at all this, I would go see the patient.
  • Make sure to know any major events that happened over the past 24 hours. Did the patient get a procedure? Were there any changes in their mental status? As the medical student, you will not be the first person made aware of these things. In fact, very often, your intern or resident will know first because nurses call/page them directly. The only way you can know this information is by making it your priority to stay informed, keep in touch with the nurses, and tell your intern/resident that you want to stay involved so they give you information as it comes up.
  • Always remember to think GLOBALLY about the patient as well. This includes things like:
    • Is the patient on IV fluids (and if so, should they be)? Are their electrolytes low? What diet are they on? Do they need some type of medication for GI prophylaxis? What medication are they on for DVT prophylaxis and why? What lines and tubes do they have in (including arterial lines, peripheral IV’s, central lines, foley catheters, g-tubes etc), what date were they put in, and do they still need them? What is their code status? What is the contact information for the patient’s next of kin?
    • As a medical student, you have the most time of anyone else on the team because you will be carrying less patients than the interns/residents. This means you should be the EXPERT on the details about each of your patients.
    • Quick note: if you know something about your patient that your intern or resident doesn’t know, NEVER try to show them up in front of the attending on rounds. REMEMBER: the game is how many people know you and LIKE you. That’s rude and embarrassing, just don’t do it. If you have information you think is important, make sure to pull your intern aside and let them know. It’s also important for patient safety: as a medical student, you may not know if immediate action needs to be taken based on the information you have.
  • If you are on an outpatient rotation, all of this changes. Instead of the above tips, look at the previous notes in this clinic for return patients and have an idea of what the interval plan was supposed to be so you can follow up on how well the patients complied, and how well treatment plans worked. If it is a new patient coming in, know which questions to ask them based on the rotation you are doing.

Develop a system for presenting on rounds.

  • As previously stated, find out from each attending how they want the medical student to present on rounds. Do NOT watch the interns/residents present and assume the attending wants you to present the same way. Attendings often want the students to give more detailed presentations than the residents, including normal lab values and normal physical exam findings.
  • Try to run your plan by the intern before presenting. There won’t always be time for this, but it is helpful if you can.
  • Usually, the attending will want you to present in some version of a SOAP format:
    • Subjective: What happened overnight, how the patient feels this morning etc
    • Objective: Vitals, Labs, Imaging studies etc
    • Assessment: One-line statement summarizing who the patient is and what you think is wrong with the patient.
    • Plan: What the team should do for the patient, usually organized by problem
  • The SOAP format can be modified in many ways. For example, some attendings will want you to start with a summary statement similar to the assessment before you start talking about the subjective.
  • I found it helpful to have my information written out on a sheet of paper in the order I would present it so my presentations were organized and I didn’t forget things.
  • Here’s a potential kicker: some attendings DO NOT WANT you to read off a paper for your presentations. Some are ok with you having a paper for reference as long as you aren’t reading verbatim, others don’t want you to look at a paper AT ALL. For the record, I think those attendings are RIDICULOUS, but they exist. I had multiple attendings force me to present without any references. If you are on a rotation with this type of attending, you MUST come in earlier so you have time to get all the information you need, and then truly digest the information so you can present without cues on your paper. Sorry, I don’t write the rules, I’m just trying to give you the tricks of the trade. You can’t say I didn’t warn you!
  • Learn how to go through a chest x-ray and an EKG before starting your medicine rotation. Just know or memorize some systematic way of going through them.

Interacting on rounds:

  • I’m sure someone has told you in the past that there is no such thing as a stupid question. I’m sorry, my friend. They lied. Questions that you could easily find the answer to on your own make you look like there are key gaps in your medical knowledge. Here is the golden rule for appropriate questions on rounds/in the OR/in general:

IF YOU CAN EASILY GOOGLE THE ANSWER OR LOOK IT UP ON A REFERENCE WEBSITE OR BOOK, DO NOT ASK IT.

  • Look up original articles on topics related to your interesting patients on a regular basis. Be prepared to talk about the things you read on rounds. Be careful not to be annoying about this though; find ways to casually integrate one or two lines about something you read in a recent article while you are talking about the plan as opposed to stopping rounds for a dramatic presentation.
  • If you don’t know the answer to a question on rounds, say “I’m not sure, but I’ll look that up and get back to you.”
  • If an attending tells you to look something up and report to him/her later, actually look it up! Some students will just hope the attending forgets, but YOU will be better than this. Look up the information, and if they forget, remind them casually the next day. “Oh, Dr. B, remember when you told me to look up the proper treatment for such-and-such?” The attending will be pleased that you followed up on the learning opportunity. Three brownie points for you! Just don’t do this when things are busy or people are rushing around. It’s all about timing and flow.
  • Find ways to be helpful without being in the way. Learn where the team would prefer the medical students to stand or sit. Follow up on labs and tests. Pay attention to how the team positions themselves around the patient’s bed on rounds so that the attending has easy access to the patient for physical examinations. Note where the light switches are in the rooms so you can turn them on or off as needed. Take note of what size gloves people wear so you can pass them along. If a particular resident is always asking for saline or gauze or tape, carry some around in your pocket and provide it when they ask.
  • Try not to be annoying. This is really hard, because “annoying” is subjective. Avoid  constantly following residents/interns around, and asking questions when people are clearly busy or stressed.
  • For surgery, it is particularly important to be helpful without being in the way. When you know you’re going to scrub in on a case, find out which OR it will be, try to go in early and help set up IF the techs/nurses want you to/find that helpful. On some surgery rotations, it is even appreciated if you help prep the patient before the attending comes in. learn what size gloves people use and have them out and ready. Always identify yourself as the medical student when you walk in. Review pertinent anatomy before cases. Don’t distract the attending when he/she seems very focused. Try to find more relaxed moments to ask questions/make observations.
  • Take note of “TO-DO’s” for your patients and offer to help with the ones that can be done by a medical student. You likely cannot place orders or do procedures, but you can offer to call family members to update them on the patient’s progress, or follow up with the social worker regarding the status of a patient’s rehab placement, or running a stat blood sample down to the lab. By doing these little tasks you are being truly helpful to the team, making your intern/resident’s life much easier, and taking charge of your patient’s care.
  • If you are told to leave early, feel free to leave early. You can give some pushback if you really think of a way you can be helpful, but to be honest most of the time you staying there just means more work for the resident/intern. Go home early, read, study, eat, see the sun.

Ask for feedback.

  • ALWAYS start the rotation by asking what is expected of you! After that, at certain intervals (ie weekly) ask for feedback about whether or not you are reaching their expectations. Make changes right away based on their feedback.
  • If I was going to be working with an attending for two weeks, my feedback schedule would be something like this:
    • Day one – ask for expectations
    • Day 7 – ask for brief feedback
    • Day 12 or 13 – ask to schedule a brief meeting for feedback at the end of rotation
  • When you ask for feedback, make sure you are specific. The average person isn’t great at giving constructive criticism because it is awkward. So when you ask, “How have I been doing on the rotation?”, a typical answer will be “Oh, you’ve been doing just fine!”. Four weeks later, when you get your evaluations back, you’ll be shocked when they rate you straight 5/10 on all categories. To avoid this, don’t let attendings get away with weak feedback like “You’ve been doing just fine!”, which means absolutely nothing. Follow up with, “Thank you so much! What can I do to be even better during this next week?” When you ask this question, preceptors are forced to actually THINK and give you something to work on.
  • Make sure you actually make the changes they suggest! You should NEVER have to be corrected on the same thing twice. If you get pimped about a topic, make sure you go learn it COLD. Some attendings like to ask you the same question later in the rotation to make sure you learned the answer. The WORST thing you can do is get the same thing wrong twice. That makes it look like you simply don’t care. If someone makes a comment about you being the last medical student to show up every day, be the FIRST to show up from that point on. If they tell you to read more, READ MORE. If they tell you to speak more loudly on rounds, SPEAK MORE LOUDLY on rounds.
  • Going back to my point earlier about not taking things personally, if you follow all this advice and still get an average or bad evaluation at the end, DON’T TAKE THIS PERSONALLY! It really does happen to the best of us. There are some attendings that give bad evaluations to everyone. There are others that pick ONLY ONE student per cycle to give an outstanding evaluation to. There are yet others that grade you against “resident-level competency” and therefore give all medical students average grades because they are not on a resident’s level yet (very unfair). DO YOUR BEST and then shrug off the rest.

Letters of recommendation:

  • If you are on a rotation with attendings that you will want letters of recommendation from, make sure you let them know you may be interested in this early. I would often wait until I had worked with them for one to two weeks or so, and then after a feedback session, I’d say: “Thank you so much for the feedback! If I were to improve in the ways you suggested, by the end of the rotation would you feel comfortable writing me a strong letter of recommendation?” Other people feel that it is awkward to ask early, and would suggest you waiting until the end of the rotation. Either is fine, but I liked to get an idea of their vibe earlier than later. If their answer to that question was wishy-washy, or lacked enthusiasm, I knew that it would be unlikely for their letter to be strong and that I needed to start thinking about additional letter writers.
  • If you want until the end to ask, still make sure to ask if they can write you a STRONG letter. Use your intuition to gauge their response. If they seem hesitant, it will NOT be a strong letter.
  • Feel free to ask as many faculty members for letters as you would like. You can pick and choose which letters you apply to certain programs on ERAS later. Also, you don’t have to use all of your letters. It’s good to have them, though, just incase.

Case reports:

  • If you are on a rotation and you are involved in the care of an interesting or unique patient, offer to write a case report if you have the time. Not only will this make you look like a rock-star, it will also allow you to develop closer working relationships with the residents/attendings who are co-authors, and it will also result in an extra research publication for your CV and ERAS application. Do as many of these as possible.

THINGS YOU SHOULD NEVER DO

  • Lying. NEVER, EVER LIE. I’m not sure why it works out this way, but the day you say you looked at someone’s leg and there was no lower extremity edema, you’ll have a patient who had bilateral below-the-knee amputations a few months ago. One of the most PAINFUL things I had to watch during third year, was an attending berate a medical student for lying that he saw a head CT for a patient. The student said the head CT had been normal. When we looked at it on rounds, there was a large brain bleed causing a midline shift.
  • Never report physical exam findings you didn’t see because your intern/resident said it was there or because it was in a note
  • NEVER disrespect nurses or other staff. I don’t think I need to give a reason for this. Just be a good person. Also, you are not ABOVE the nurses. The nurses have a completely separate career and job than the one you are training for. They are experts in their field, and you are simply a trainee in yours.
  • NEVER pimp your intern/resident in front of the attending.
  • Never document or report an important finding without telling your intern/resident
  • Never do a procedure on a patient by yourself.

That’s it for now, part 2 on mindset and part 3 on away rotations, both dropping later in the week!! PLEASE SHARE!!!

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