Are you suffering from roundsitis? Hypercaffeinemia? Overnight call adjustment disorder? Scutworkophobia? My friend, there is hope. I strongly advise you to look into the specialty of emergency medicine – in which the medicine you practice is practical, your time is spent saving lives rather than writing notes, and you miraculously find yourself at home at the end of every workday, wondering how you got to be so lucky.

In emergency medicine, as in all specialties, there are rough days and difficult patients, and you will still end up cursing our broken healthcare system as you struggle to get paid for what you do. However, EM is known for its humane work hours, diverse patient population, and efficiency.

As a medical student or even a resident, working in emergency medicine can be a breath of fresh air. To go from toiling through paperwork on the wards and spending more time with a patient’s lab values than with the patient, to seeing and treating patients one-on-one with an attending can be an exhilarating experience. Somehow, knowing you have tweaked a floor patient’s magnesium value just doesn’t have the same thrill as halting a seizure with Ativan, waking up an apneic patient with Narcan, or cardioverting a patient in atrial fibrillation. Even the little things in emergency medicine can be very satisfying: relieving pain and nausea, repairing lacerations, splinting fractures, and draining abscesses are all easy ways that you can instantly fix a patient’s problem. If you like procedures but fall asleep in the operating room, you really need to try emergency medicine.

Sadly, many medical schools do not allow students an opportunity to rotate in the emergency department until fourth year. This leaves a very short amount of time to pull together your residency application if you fall in love with it. If you suspect you would be happy in EM, you should definitely try shadowing an emergency physician for several days (or even better, nights) as a first or second year student.

Consider the following list which I have always found very helpful – credit goes to Desperado in the EM Forum here on SDN:

1. The Emergency Physician (EP) sees his profession as a job, not a calling. You will notice in your medical school class that there are those who live, eat, and sleep medicine. Those people typically do not go into EM. EPs typically have many outside interests, and are interested in a job that allows them to pursue those interests as well as medicine.
2. EPs love working up undifferentiated complaints. They got upset in their third year medicine rotations when they were told to go down to the ED and work up the guy with the COPD exacerbation. They wondered, “If I already know he has a COPD exacerbation, what’s left to work up?”
3. EPs think a doctor-patient relationship is what you have when someone gives you a chart with a patient’s name on it, not what happens after following someone’s hypertension for 10 years.
4. EPs like to do procedures. They think sticking people with needles is fun.
5. EPs aren’t afraid to make a decision on limited information.
6. EPs like to work as a team. They know what their nurses do outside of the hospital, and nurses call them by their first names.
7. EPs like to multi-task. EPs prefer to work while they’re at work.
8. EPs prefer a specialty of breadth to a specialty of depth. They enjoy learning practical information, and using common sense.
9. EPs enjoy being able to take care of people from all walks of life, rich, poor, old, young, smart, stupid, etc., without having to worry about whether they can pay you.
10. EPs typically enjoy a large percentage of their medical school rotations. They often think psychiatry is interesting, just not necessarily something they’d like to do all day. They enjoyed surgery, they enjoyed ICU, they may even have liked OB/GYN. They usually liked internal medicine, but detested rounding for hours and writing 10-page-long notes.

How to Succeed on Your EM Rotation

So you’ve decided to go into EM, and you want to ace your rotation. As on any rotation, the biggest keys to success are being enthusiastic and hard-working. Importantly, though, there will also be a few other personality traits that your residents and attendings will be looking for.

bility to get a brief H&P that still includes all the pertinent details. Aim for your H&Ps to take about 10 minutes if possible. Remember, this means you need to work on skills like re-directing patients during interviews. You can still start with an open-ended question, but after that try to focus in and get the positives and negatives that will help narrow your differential, and focus on your CODIERS questions (Course, Onset, Duration, Intensity, Exacerbation/Remission, associated Symptoms). One of the hardest things to remember as a medical student is that you are there to identify potential urgent/emergent causes of pathology. This means that you will have to set aside items that are non-emergent for the discharge instructions to be worked up as outpatients.

As a follow-up to getting a brief H&P, you must be able to present the patient in a concise manner. Try to take a few moments to organize your thoughts before launching into your presentation. Lead with a statement including age, gender, and chief complaint, potentially adding any significant medical history. For example “35-year-old woman presenting with leg pain” is not the same as “35-year-old woman with past medical history of tobacco abuse and Factor 5 Leiden deficiency presenting with leg pain”. A good opening statement should ideally put a differential into the listener’s head. After presenting CODIERS, pertinent positives and negatives from the review of systems, and past medical history, go to physical exam and only mention pertinent findings. Leading with vital signs is a good idea (i.e. “afebrile, tachycardic in the 110s”) then hit the high points. Always include cardiac and lung exams (i.e. “lungs were clear, heart exam normal, no murmurs”) and then try to stick to anything unusual or relevant to the chief complaint.

Have a differential and plan. It doesn’t have to be extensive. Have at least 3 differential items, and definitely include the most dangerous possibility as well as the most common. For example: chest pain – acute coronary syndrome and reflux (aortic dissection would be another good one to add). Don’t forget, the patient does not have to fit the diagnosis perfectly, the important part is that you are actively considering the possible diagnoses. Don’t overthink things. For the plan you can always order the cheap, easy tests. Think of orders in common sets like “CBC, Chem 7, EKG, chest X-ray, cardiac enzymes” or “CBC, Chem 7, KUB, U/A, pregnancy test, LFTs”.

Come early, stay late, and give good sign out. Don’t leave without ensuring that your patients are being followed up on.

Be courageous, but not foolhardy, about volunteering for procedures. If you’ve never seen a procedure, ask if you can see one first. If you’ve seen it, ask that someone to walk you through it. When you feel comfortable with trying it on your own, be aggressive about asking for the opportunity to do it. Try to get experience with lumbar punctures, suturing, A-lines, paracentesis, and splinting, and observing procedural sedations, dislocation reductions, and central lines. Do as many ultrasounds as you possibly can. If you have a good attending or resident, try to attempt a central line or intubation. Always ask if you can attempt the procedure – the worst that can happen is that they say no, and at least you will appear eager to learn.

Don’t overextend yourself. No one should expect you to do the work of a resident. Just take two patients, or maximally three patients, and try to do your best job on them.

Best Books for Your EM Rotation

It is hard to recommend books, because different personalities may mesh better with different types of books. Here are the things I recommend to any intern or medical student in the emergency department:

• A general reference for your pocket: my suggestion is either the “Tarascon Emergency Medicine Handbook” or the “Pocket Medicine: Emergency Medicine” book (the little black book). Another one I like is “Emergency Medicine Pearls.” As a medical student having a book like the Pocket Medicine book or the EMRA pocket book will be key to acing your rotation, because you can look up the patient’s chief complaint and have a plan for tests and treatments when you present to the attending – crucial!
• A general drug reference: you have to prescribe and think about many different medications in EM. I recommend having ePocrates on your Palm or carrying Tarascon Pharmacopoeia if you don’t have a Palm. You don’t have time to use the computer.
• A specific antibiotic reference: I think the Sanford Guide is equivalent to hieroglyphics. If you really like ID, carry Sanford, otherwise, download the JHU Antibiotic program free for your Palm or carry the EMRA Antibiotic Guide, which is more like “Antibiotics for Dummies.”
• The ACLS algorithm cards — because you never know. Don’t enter the ED without them.
• The EM Rules Palm program — another excellent free download. Be able to run many important EM algorithms “in your head”! The creator is right here on SDN.

You do not need to buy an EM textbook for your rotation, it is too much information, and when you are a resident, your program will usually give you its preferred text.

If you have further questions about your rotation in EM, the SAEM website is a wonderful resource.

Also, the SDN Emergency Medicine Forum is full of fabulous residents and a number of attendings who are happy to answer questions – as long as they haven’t been asked a million times before. Visiting the EM forum requires strict forum etiquette, so search your query first, and read the FAQ, or you may find your question buried in a sea of witty retorts and Chuck Norris jokes!

The international elective, whether done in the summer after first year or in an elective block during fourth year, has become a virtual staple of medical school. The rising number of medical students who participate in such experiences reflects an increased awareness amongst medical students of global health issues such as access to health care for under served populations.

Many students spend long hours researching such opportunities, since so many diverse types of experiences exist worldwide. Choosing one of these opportunities can be a daunting process, particularly for students with a newly minted interest in global health who are trying to find a meaningful first experience.

Types of experiences

There are a number of types of experiences that health and pre-health volunteers may seek, and they are quite different from one another. Here is a list of some of the most popular international options:

International elective in an industrialized country
This category would be for students who are seeking a clinical experience in a place such as Europe. As with any away rotation, the availability of such an elective is dependent upon finding a preceptor at an institution you would like to visit, and then arranging whatever paperwork your school requires to receive credit. If you have no connections at the institution or in the area, and you can locate contact information, sending e-mails to likely preceptors in the specialty in which you would like to rotate is an easy way to screen for potential opportunities.

This type of opportunity is a fascinating way to see how medicine is practiced in a system outside the United States, and the ways in which that practice differs both in terms of treatment of illness and in terms of administration of and access to healthcare. You may also elect to work on a research project rather than doing a clinical-only experience.

International elective in a developing country
This option also involves clinical or research work, but in a health care institution that is in a resource-limited or impoverished setting. This exciting opportunity allows medical students to work in an area where health care professionals are desperately needed, and to have an eye-opening exposure to what most of the rest of the world has for health care. It can be fascinating to realize how physicians function with minimal laboratory and imaging capabilities. You may gain a new respect for physical diagnosis, which may often seem to be a brief precursor for a battery of blood work and body scanning in technology oriented Western medicine.

The challenge faced by students who travel to developing countries, particularly for 4th year students, is that they are motivated by internal and external forces driving them to provide actual clinical care to patients in great need (i.e. being the person with the most medical knowledge and experience in a remote area with few or no physicians at all available). As students who have little experience with provision of direct clinical care, this is certainly an ethical dilemma.

Things to keep in mind

• All countries have laws governing who can legally practice medicine. You must be aware of these laws and discuss with your mentor or preceptor the legal guidelines under which you will be working. If you have no mentor or preceptor, you should be aware of any legal ramifications of your actions while abroad.

• Safety equipment, including gloves, masks, gowns, and clean needles may not be available or commonly used in some settings. Ensure that you have a supply of gloves and practice appropriate universal precautions, even if those around you do not. Risking your health is not courageous; it is foolish.

• Some believe that “any medical care is better than nothing”. This is a fallacy. Western medical treatments often have side effects that are not benign. It is also unethical to imply that those living in poverty do not have a right to expect high quality medical treatment. Paul Farmer, an icon in global health, has been integral in advancing the opposite idea: a ‘preferential option for the poor’.

• Many drugs that are only available by prescription in industrialized countries are over the counter in developing nations. Just remember, before you attempt to treat a patient who comes to you for help as a prestigious ‘American student doctor’ – even a simple antibiotic can cause anaphylaxis. In a place where few options to treat an adverse reaction, are you comfortable with that risk? It is a difficult question, exacerbated by the fact that American students are heavily trained in American health problems, such as heart disease and diabetes. This leaves us uniquely disadvantaged in a location where tropical infectious diseases cause the majority of burden to the population.

Other options for international volunteering

Partially due to the challenges addressed above, which are associated with clinical work, many students choose a public health-oriented project, particularly during the summer after first year. These projects are usually located in developing countries, and often involve health education/promotion and awareness-raising activities. They may also involve disease prevention campaigns or physical projects to improve community health such as building water wells.

Such opportunities are often highly rewarding, and give students the satisfaction of addressing underlying health issues in communities where treatment of disease can be futile without changing the sanitation, hygiene, and prevention strategies of entire communities. Again, as with research, it is often easy to find opportunities for clinical experiences and shadowing within such projects. For example, shadowing a doctor in Africa who is the only physician in a district of 200,000 inhabitants as he circulates through various area health centers is a priceless educational experience in the firsthand effects of the ‘brain drain’ of healthcare and other professionals from developing countries.

Tips for Success

1. Use a trusted resource guide to find opportunities.

Some schools and other Web sites compile lists of potential opportunities for health and pre-health students (You can find some of the most well-known listed below under ‘Resources’). However, these compilations are usually not reviewed by anyone and thus may contain opportunities that are not high-quality. These opportunities should be investigated with caution – let the buyer beware!

For this reason, students should look into programs that are endorsed by sources that have some sort of quality control, or are recommended by someone you know. This is your only way to ensure that you do not end up stranded in a remote corner of the world with a program that is not a good experience. There are also some databases of opportunities that include reviews from former participants. Unfortunately, these are usually restricted and not publicly available.

2. Consider the safety of the location.

The State Department has a list of travel warnings and ‘Consular Information Sheets’ which can be viewed by country. Please review available information carefully before planning your trip. Proceed with caution if the country in question has a current travel warning. It is advisable to do your elective with a friend if possible. You should know all the details about the safety of the place in which you will be living and sleeping as well as the place you will be working. Transportation is also important to consider, as many places in the world have public transportation with extremely varied levels of safety.

3. Be fluent in the local language.

You must speak the local language at least passably if you expect to see patients in anything more than a ‘shadowing’ type of experience. As anyone who has used a translator knows, interviewing patients in a different language is sub-optimal at best, completely misleading and confusing at worst. Do not assume that people in rural areas speak the national language.

4. Be ‘fluent’ in the local culture.

When you travel, be a good ambassador for the United States. Be polite and respectful of local customs, social mores, and dress. Do not wear revealing clothing, period. Be aware that in other countries, public displays of affection may not be appropriate. Know the place you are traveling to and in what ways you might offend people.

5. Have realistic expectations.

If you are a first year medical student or otherwise have little experience with patient care, do not expect to be involved in high-level direct care. Concentrate on learning, and remember that you have the rest of your medical career to treat patients. Know the details of what your program involves. Ask questions if the descriptions provided by the program do not give you a clear idea of what you will be doing. Not being sure what you are signing up for can lead to disappointment. Remember, things in other countries may move at a slower pace. You may need to adjust your type-A medical student mindset. Enjoy it and relax.

6. Find a good mentor.

The best mentors are local to the place where you will be practicing, but an acceptable option is a mentor who has traveled to the location in question and has a great deal of experience there. Of course, all mentors should be teaching and learning-oriented and good role models for safety, ethics, and evidence-based practices. If you cannot find a suitable mentor at your home institution, don’t despair. Finding one via the internet may take only a small amount of initiative. Many medical school faculty members travel abroad regularly and have a profile on their institution’s website that would turn up in a quick web search. If you are planning to travel to an under served area, you may want to consider a mentor who is familiar with health and human rights issues and has experience working in resource limited settings. Ideally, your mentor will be the main person with whom you work while traveling abroad.

Resources

- AMA: http://www.ama-assn.org/ama/pub/category/12675.html
- AMSA Global : http://www.amsa.org/global/ih/ihopps.cfm
- ARHP (Reproductive Health): http://www.arhp.org/files/InternationalDirectory/pdf
- IFMSA-USA: http://www.ifmsa-usa.org/priorities/scope.htm
- Idealist.org is a fabulous resource for interested volunteers of all ages and types

About the author

The author is a co-founder, former director, and current assistant director of the Uganda Village Project (www.ugandavillageproject.org), as well as a former member of the IFMSA-USA Board of Trustees.

Family Medicine can also appear daunting because of its wide scope of practice. For those students completing this clerkship early in their third year – before they have been exposed to some of the other core specialties – seeing pregnant patients, small children, or chronically-ill patients can be intimidating.

In order to quell some of the anxiety that may arise, the SDN Front Page has compiled a survival guide to help you get the most out of this challenging and rewarding part of the third year. This guide is based on the author’s own experiences on family medicine clerkships and information provided by Dr. Anthony Jerant, director of the Primary Care third year clerkship at the UC Davis School of Medicine. Because not all primary care clerkships are structured the same way, you may find some differences between what is described here and your clerkship experiences at your own medical school.

The Setting

If your Family Medicine clerkship is a primarily outpatient experience, you will be assigned to a faculty preceptor who is a family physician. Since the field is very broad and encompasses a wide variety of practice types, you may be assigned to a preceptor in solo practice, group practice, HMO setting, or academic center. Some schools may offer the option of doing the rotation at a rural site located away from the main medical campus. Often these sites will provide housing and meals and can be a great opportunity to experience what practicing medicine is like in a rural area.

The Schedule

At the beginning of the clerkship the faculty preceptor will usually discuss the office’s schedule with you. Some students work regular office hours on this rotation and others may be assigned to sites that work extended hours. If the preceptor has patients in the hospital or does obstetrics, you may attend hospital rounds in the morning before heading to the office, or may have the opportunity to help with deliveries at all hours of the day or night.

There may be other clinical and educational activities scheduled during your clerkship as well. At UC Davis, for example, students leave their assigned preceptors for several half-day sessions in outpatient geriatrics, hospice, home health care, and physical and occupational therapy, and also attend weekly case discussions of common topics in primary care.

Preparation for the Clerkship

There is really no specific preparation for this clerkship. The basics of taking a history and doing a physical exam that are taught during the first two years of medical school are the skills that are most important. You may find that having some clinical experiences in the outpatient setting, such as interviewing and examining patients at student-run clinics during your pre-clinical years, is helpful. Experiences from other core clerkships, including internal medicine, pediatrics, obstetrics, and surgery will also be helpful for students taking the Family Medicine clerkship later in the third year.

Goals of the Clerkship

This rotation seeks to increase your understanding of the primary care physician’s role in the medical system since all students, regardless of future specialty, will have some interaction with primary care during their careers. Preventive medicine is a large part of primary care, so you will become familiar with how to screen for and to counsel patients about preventing illnesses. Given that primary care physicians see a wide variety of complaints, you will learn how to diagnose and manage the most common presentations. The clerkship provides a great opportunity to work on history and physical examination skills, particularly learning to address the patient’s concerns under the time constraints of the typical outpatient office visit.

Typical Day

On a typical day on the Family Medicine clerkship, you will see patients with the faculty preceptor. Many preceptors will give you your own patients. After introducing yourself, taking an initial history, and doing a brief physical exam, you will present the patient to the preceptor. They will then help you develop a treatment plan for the patient and will then usually see the patient with you to conclude the visit. Since many practices are very busy and can see 30-50 patients daily, the preceptor may be seeing several other patients while you are seeing one. Be aware that there may be significant downtime while waiting to present to the preceptor and that the discussion may need to be brief to maintain the flow of patients. Use available time to formulate a concise presentation of the patient’s complaint and exam findings, develop a differential diagnosis, and gather any lab slips or paperwork that may be needed to expedite the remainder of the visit.

Seeing patients and presenting them to your preceptor will constitute the bulk of your day at most placement sites. You may also have the opportunity to observe and help out with office-based procedures like punch biopsies, vasectomies, circumcisions, endometrial biopsies, suturing, and incision and drainage. Once you get to know the flow of the office you may also help the nurses and medical assistants with vital signs, blood draws, and injections. Outpatient primary care preceptors typically enjoy teaching and their office staff may be used to having students. In fact, nearly all clerkships employ preceptors who volunteer their teaching time, indicating the level of dedication they have for student instruction. Do not be afraid to ask if you need help or are unsure of something.

How To Do Well

The breadth of family medicine is very wide; keep in mind that you are not expected to recognize every patient’s presentation. You will see the most common complaints and chronic illnesses, like cough, back pain, diabetes, and hypertension many times on your clerkship. However, rather than coming to view them as “old hat” or routine, the great challenge (and art) of primary care is to learn to best apply the generalized knowledge you accumulate about these common topics to the specific circumstances and needs of each individual patient. Every patient encounter is quite unique; even those concerning these common ailments. To remember this very important principle during your clerkship, you might keep the American Academy of Family Physicians catchphrase in mind: “The doctors who specialize in YOU.”

To build a knowledge base of such core concepts, you should focus on reading about some of the chief complaints you see during each day. Tying the material in to specific patients will help you remember what you read, and if you do it just after seeing a patient, it will allow you to bring up questions you have about management with your preceptor while the encounter is still fresh in your minds. Think of this time you use reading as putting in your “call” as you might on an inpatient rotation. This is just the start of the lifelong learning you will be doing as a practicing physician in your chosen specialty.

As with any other rotation, being professional — showing up on time, treating staff courteously, and dressing appropriately — will be noticed and appreciated. Remember, family medicine strives to treat every patient as an individual and to address the patient as a whole person and not just a collection of organs and symptoms. Get to know your patients as much as possible and use this rotation to strengthen your interpersonal communication and listening skills. You may have more time with the patient as a medical student, and your preceptor will appreciate hearing about the patient’s concerns that may not have been addressed at past visits due to lack of time.

Reading Materials and Examinations

To augment your knowledge, Sloane’s Essential of Family Medicine and accompanying practice question CD is used by the clerkship at UC Davis. The instructors of record advise that students spend as much time on reading and studying as they spend doing overnight and weekend call on other rotations.

Most schools have some form of a written exam at the end of the clerkship. Clerkships may create their own exam or use an National Board of Medical Examiners (NBME) exam. Be sure you stay on top of your reading because many students find these exams to be very challenging due to breadth of the material, especially if they are taking it early during third year. Ask the clerkship directors for your course or other students from your school what you can do to best prepare for the type of exam your school offers.

The following books and questions banks, listed in no particular order, have been found by some students on the Student Doctor Network to be helpful when preparing for the NBME Exam in Family Practice:

Textbooks/Pocket Books
Case Files in Family Medicine (presents common presentation in case-based format)
Swanson’s Family Practice Review (designed for Family Practice board exam prep)
Blueprints Family Medicine (very broad overview of many conditions)
Step-Up to Medicine (outpatient medicine section)
1st Aid for Step 2 CK or Step 2 Secrets or Boards and Wards (outpatient medicine, Peds, and Ob-Gyn chapters)

Question books/banks
NMS Family Medicine Q&A
MKSAP (Internal Medicine questions)
Sloane’s Family Medicine Essentials CD (100 questions, comes with textbook)

The family medicine clerkship will introduce you to the most important aspects of primary care. Whether you decide to pursue a career in this area or not, use this rotation to work on your history taking and physical exam skills, and to build your knowledge base in the basic areas of medicine, pediatrics, and obstetrics and gynecology that will serve you well in all areas of medicine.

To discuss this article on the SDN Forums, click here.

by Alison Hayward, MD

Nearly every medical student, at some point during training, will have a negative encounter with someone higher up on the ladder. One of the most difficult aspects of medical school is the vulnerability of medical students to criticism or disciplinary action due to these types of encounters. These situations can lead to the most dreaded of outcomes – a negative comment in your dean’s letter or file.

Your skills in interacting with others will be put to the test not only with patients, but also with physicians and support staff.  Oftentimes, a perceived offense to the ancillary personnel can be particularly damning, because physicians often have close relationships with these staff members.

This can also work in your favor: getting in the good graces of the rest of the staff can help secure a favorable impression on your supervisors. Remember, some attendings may be quite removed from your daily activities as a medical student. If this is the case, they may count on secondhand reports from other staff members as part of your evaluation.

With seemingly innumerable potential pitfalls, the third year clerkships in particular can be maddening. At no time are you lower on the totem pole, and sometimes it can feel like other staff members – particularly those normally at the bottom of the pecking order – revel in making you feel completely clumsy and irrelevant. It is a difficult situation to be in, but the key is to keep smiling. Being cheerful and enthusiastic, as many students who have excelled on the wards know, is usually more important than getting “pimping” questions correct. Many attendings believe in a variation of the adage, “knowledge can be taught, but personality is forever.”

Students can often be heard bitterly complaining about the subjective nature of clerkship evaluations. Since evaluations of one’s personality are necessarily subjective, and personal interactions will figure prominently in nearly any career, there is little chance that clerkship evaluations will cease to be an important factor in residency admissions. Being able to “play nice” will help you in any profession, regardless of your mastery of the facts or your physical ability to do procedures. Therefore, simply raging against the machine, while perhaps cathartic, is not the solution.

So what are your options, aside from being relentlessly pollyannaish and striving to get along well with everyone you meet? If you have an abrasive personality or commit a truly heinous act, then prayer may be your only resort. However, if you are like many medical students and have been misconstrued in something you said or did despite good intentions, you may have alternatives.

First, apologize regardless of the situation and whether you feel the complaints are justified. Not only will you hopefully improve relations with the individual, if your future career is more important to you than the flap in question, you may avoid repercussions. Attempts to defend yourself may add fuel to the fire, because you will appear to be questioning authority.

Titrate your apology to the offense: if it is minor, a simple apology will suffice, but if it is serious, a more extensive explanation may be required. In fact, the best response to a low-level negative comment (such as the type you may receive daily from a grouchy, sleep-deprived resident or attending) is usually just a cheery “all right, I see what you are saying, I will try not to let it happen again!” Although this type of response may not only feel false but may be tough to fake, mastering it will help you deal with a multitude of situations that have the potential to go on a downwards spiral. It is also often said that the best doctors are great actors.

Second, if another authority is available who you feel will be sympathetic, go to them for help. For example, if your problem is with your preceptor, but you have a kind clerkship director, make your case to that person. If you go down this road, never appear to be accusing the person who criticized you. Explain it in terms of being a misunderstanding, or propose extra credit work you could do to remedy your grade. If you come off well in this encounter, this person may leave out the offending comments or alter your grade accordingly. If this option is not feasible, or if the person you appeal to is unwilling to change their colleague’s ruling, consider giving up. Further pushing may get you into more trouble.

Finally, as a last resort, find out if your institution has an “ombudsman” or “ombudsperson”. These individuals act as student advocates in situations where students have been intimidated, harassed or otherwise wronged by faculty members. Ombudspeople are meant to serve as equalizers in the large power differential between students and attendings.

If none of the above is helpful or appropriate, consider writing a letter that you will not send stating your grievances. You will likely feel better after making your case on paper/in e-mail, but you will not risk getting yourself in deeper by appearing to accuse, blame, or inflame those who are above you.

Above all, the rule in clerkships is to try to avoid the negative encounter in the first place. Remember that you are being watched. The way you talk, the way you dress, and the way you treat patients are being minutely scrutinized. Remember that one of the most common accusations leveled against medical students is that they have acted “unprofessionally”. Avoid any language that even borders upon ‘colorful’, even if you are only in the company of colleagues. Do not make jokes with colleagues or patients on any political, religious, or personal topics, particularly about the patient’s appearance. Do not complain about a co-worker’s behavior to another staff member unless it is of crucial importance to do so.

It is also prudent to avoid giving negative feedback (about persons or activities on the rotation) in general, unless you can do so anonymously. You are not protected from repercussions otherwise. You have the rest of your career to be opinionated and blunt. As a student, stay conservative and positive. And, because expectations of students can be unrealistic, if you cannot avoid a reprimand, use the tips above to counter it.

To discuss this article, please visit this thread in the SDN Forums.