Getting the Most out of Clinical Rotations
I can summarize this ensuing section in just two words: “active involvement”. But what does that mean with respect to clinical rotations? And how does a student ensure that he/she shines while rotating through clinics? I’ll first talk about the general structure of clinical rotations, and how to behave and communicate effectively. Then I’ll delineate SPECIFICS on establishing goals and expectations from the start, allowing you to attain the best evaluations possible (clinical grades carry far more weight than Basic Science courses).
Clinical rotations are broken down by service into hierarchical teams. The particular service for that rotation may be Anesthesiology, Cardiothoracic Surgery, Internal Medicine, etc. The teams are arranged in totem-pole fashion. The attending physician sits atop this hierarchy and is ultimately responsible for the team and guides decision-making to ensure proper patient care. There may be a fellow (a doctor seeking advanced sub-specialty training after completing residency), who assumes a similar albeit subordinate role to the attending. Below this are senior and junior residents. Residents bear the brunt of day-to-day patient management and are the first contacts for whenever something goes wrong or something needs to be done. And finally, there is the medical student…a despicable creature scurrying about not knowing anything but succeeding in being thoroughly annoying…oh wait…just kidding. That’s what you don’t want to be. And here’s how.
Being on a hospital team is a professional work environment. It is quite different from being another face sitting in a large lecture hall. You have real roles and responsibilities beyond simply studying to regurgitate information for a test, and there are professional standards to which you must adhere. One of the most important attributes for a medical student to thrive and be impressive in this setting is EFFECTIVE COMMUNICATION. I can recount many examples of fellow students getting so nervous or anxious that they stumble over words, lose their train of thought and jump all over the place when describing a patient problem. This is such a prevalent phenomenon that there are stores of Internet memes poking fun at it. But it doesn’t need to be so.
First day of clinics
Personally, I was not even close to the top of my class in terms of test scores and grades in the Basic Sciences during the first 1.5 years. However, I did extremely well in clinics and received phenomenal evaluations from attendings and residents. Several of my residency interviewers even read me the comments directly from my application and remarked on how impressive they were. The reason for this is fairly simple. All students (not just myself) who perform well in clinics have effective communication skills. Often times, your only interaction with the attending will be presenting patient cases on morning rounds, so you have to maximize this face time.
Be confident, calm, and collected when you present a patient case. If you’re a naturally nervous person, spend time preparing adequately. This is actually one of the most effective ways that public speakers orate with poise – by preparing exhaustively (and maybe taking beta-blockers…but don’t do that). Early on, write down your patient presentations to solidify a standardized presentation model in your mind. Adequate preparation brings clarity of thought, which allows a smooth delivery. With enough practice it becomes second nature, and you’ll do it without thinking or needing to write anything down.
Another important point is don’t be annoying. Unfortunately, this is common enough that I have to mention it. Don’t be the kid who asks a million questions just to seem interested; ask appropriate questions for the situation, things that a simple Google search may not elucidate. Don’t make your residents or fellow medical students look bad, or try to one-up anyone. There’s a term for this. It’s called a “gunner”…or in less appropriate parlance, a “douchebag”. Remember that you are a team. Collaboration is better than competition. Equally important is to go home when you’re given permission. Once your resident says you can leave…get the hell out of the hospital. You gain no brownie points for sticking around twiddling your thumbs (in fact, you probably just annoy the residents). Go home. Study, work out, chill with friends, relish your life. Maximizing your free time is paramount to enjoying your clinical years, because it is far sparser than during the Basic Science days.
Additionally, keep in mind that it’s perfectly acceptable to have casual conversations with your residents and attendings. They are normal human beings after all, and some of my most meaningful interactions with attendings in the hospital have not been about patient care but about random things like sports, sharing jokes, discussing the stock market, or even outer space. Get to know your residents and attendings on a semi-personal level, and they will in turn respect you as more than just a vessel for reciting patients’ vital signs. And your evaluations will reflect that deeper level of interaction.
The last topic in this section regards establishing GOALS and eliciting FEEDBACK. I received excellent advice from one of my mentors prior to starting clinics. It worked remarkably well for me, so I’m going to share it with you.
At the beginning of every rotation, I approached my attending and asked to speak briefly in private about their expectations for the rotation. I made it clear that I was highly interested in maximizing my time and learning potential on this rotation, and prepared to work hard. I further emphasized that I desired tangible goals to accomplish this. Every single attending I had was not only receptive to this, but impressed that I was taking such a keen interest in my education.
Regarding goals: I made sure to elicit TANGIBLE GOALS and action items on which to improve, because those are objective metrics for evaluation. Do not settle for unhelpful statements like “just keep up with your reading” or “talk to the residents about what you should do” or “be involved”. I asked specifically what AREAS STUDENTS HAVE STRUGGLED WITH IN THE PAST and what should be the BIG-PICTURE TAKEAWAYS from this rotation. For example, at the start of my Internal Medicine rotation, my attending told me that students classically struggle with ECG interpretation. I made it a point to learn all I could about ECGs and recognizing different cardiac rhythms. Towards the end of the rotation the attending actually remarked on how impressed she was by my improved ECG readings. During Neurology, my attending stated that his personal goal, whether a student was interested in neurology or not, was that every student should master the full neurologic exam (which is quite lengthy, but has excellent diagnostic potential when performed well). This is an area that students and even residents struggle with because they hastily go through the motions, rendering poor diagnostic utility to their exam. I observed how my attending performed the full exam, watched YouTube videos, and asked my residents to critique me constantly. By the end of the rotation I became very confident in my exam skills. In my evaluation, the attending even mentioned a concrete example where I diagnosed a neurological condition based off exam findings.
How I mastered the Neuro exam
The reason I provide the above examples is to illustrate how to find tangible and measureable areas of improvement. To really stand a cut above the rest, make it a point to EXCEL WHERE MOST STUDENTS STRUGGLE and acquire skills that are beyond your expected training level. You should of course not solely focus on ECGs and the neurologic exam during Internal Medicine and Neurology, respectively. You still want to learn as much as you can about the particular field and fulfill your team duties. But in addition to that, find action items similar to the above that will make you stand out. In no way did I have the highest repertoire of knowledge when I was in clinics (I often felt like I didn’t know anything haha). But I worked arduously and recognized what the attendings found impressive – simply because I asked.
A final word regarding feedback: it doesn’t have to be a formal, private conversation. Some of the best feedback and advice I’ve received has been right in the moment and informal. During the start of my first Orthopaedic Surgery rotation, I was suturing a wound at the end of a case and I still felt slow and clumsy doing it. My attending was standing there watching me, so I asked if he had any tips on suturing. He showed me how to alter my grip on the needle driver and angle the forceps to gently tense the skin without damaging it, making it easier to pass the needle through. This made me much more efficient, and I practiced incessantly till it was second nature (I got a pair of needle drivers and a bunch of suture, and sewed together orange peels, towels, pieces of foam, anything I could find to practice). My improvement of course impressed my attending, and also paid dividends when I did my Orthopaedic Surgery away rotations (more on that later).
In sum: be confident, calm, and prepare in advance. Be normal and don’t try to out-gun your fellow students. Ask for formal, tangible goals early on and meet them. Request regular informal feedback and be receptive to it. You will maximize your learning, secure fantastic evaluations, and genuinely have fun because you are actively engaged in self-betterment rather than passively flowing along with the current.