Make sure to check out Part I here!
The remaining day
Following rounds, teams will typically “run the list,”or quickly review the to-do items discussed during rounds and delegate the work as necessary. Since medical students typically cannot input orders, which include things like prescribing medications, scheduling diagnostic imaging and tests, and requesting labs, this usually involves more administrative tasks: obtaining medical records from outside institutions, following up on tests, and other ancillary tasks. Most rotations also incorporate some form of formal teaching in the curriculum. As such, students may be expected to attend lunch lectures with residents or may have their own lecture schedules. Some attending physicians enjoy giving quick teaching sessions and will set aside 30-45 minutes to talk about a particular clinical topic (e.g., management of diabetes, working up an acid-base disturbance, and other common issues) each day in addition to the more formal teaching opportunities scheduled by the clerkship.
After patient care tasks are completed, students are at the mercy of their superiors and the requirements of the clerkship for the remainder of the day. Some residents respect the time of students and are quick to dismiss them once they can no longer contribute to the day’s activities. Others are less effective managers, and students sometimes languish in the hospital for hours before being dismissed. Some clerkships require students to stay with their teams until “sign-out”–or the transfer of care to the night team–occurs, irrespective of any remaining tasks that need to be completed. In the case of downtime, residents typically welcome studying on the part of students, and making good use of any available free time in the hospital to study or otherwise be productive is essential.
Some medical schools require students to take “call” as part of their clinical experiences. While on call, the team is responsible for admitting new patients to the service as necessary and managing the patients of the other teams not on call once they leave the hospital. Call typically occurs every third or fourth day and, at a minimum, usually requires staying at the hospital later than usual. As an example, I would generally go home by 6pm while on in-patient pediatrics, but on call days – occurring every four days – I was required to stay until about 10pm or so. Many general surgery rotations require 24-hour in-hospital call to have the opportunity to participate in emergent, overnight procedures; under this scheme, students will usually stay until rounds the following morning and have the rest of the day off.
A typical schedule, or “can I have a life?”
Medical students have two broad types of experiences while on rotations: in-patient experiences, which involve caring for hospitalized patients, and out-patient experiences, which involve attending clinic and seeing patients for in-office visits. In general, in-patient services are more time-consuming than out-patient services. At my institution, spending 10-12 hours a day, 6 days a week at the hospital is typical for students on in-patient services. Out-patient services follow a more traditional workday schedule, with clinic running from 8am-5pm on weekdays only. Presented below is a daily schedule for a typical in-patient experience like that seen on internal medicine or pediatrics. Surgery schedules are similar with the exception of starting earlier in the morning in order to begin operating by 7am or 8am while spending the remainder of the day in the OR rather than on the floor.
5:00-5:45 am: Wake up and get ready for the day
5:45-6:00 am: Head to the hospital
6:05-6:30 am: Arrive on the floor and begin gathering lab data, reviewing diagnostic results, and reading overnight provider notes
6:30-7:00 am: See and examine assigned patients
7:00-8:00 am: Write notes for patients seen that morning, which typically involves some measure of outside reading in order to develop an appropriate treatment plan
8:00-10:30 am: Round with the team
10:30-10:45 am: “Run the list”
10:45 am-12:00 pm: Assist the team in any tasks, as possible
12:00-1:00 pm: Lunch, which frequently includes attending either a lunchtime lecture or conference
1:00-5:00 pm: Miscellaneous time – may be spent continuing to help with patient care tasks, studying, or other requirements until dismissed
5:00-7:00 pm: Walk home, eat dinner, and spend time with family; if on call, stay at the hospital
7:00-10:00 pm: Prepare for the next day and study; if on call, stay at the hospital
More than any of the other years of medical school, how students spend their time is largely outside of their control, making it difficult to have a regular schedule or make plans outside of the hospital. After spending hours on end at the hospital, many students – myself included – had very little energy to do much afterward beyond having some time to themselves before sleeping. In my own case, I also live with my fiancé and have pets to take care of, so spending time at home is, for me, preferable to spending nights out. That being said, many of my classmates were able to spend ample time with friends and classmates, continue to hit the gym regularly, and stay in touch with their hobbies while performing well on clerkships. Your individual goals will also shape how you spend your time: students who more strongly prioritize doing well will necessarily have to spend more time studying in order to do so. On the whole, however, it is still possible to have free time to spend as you please, though certain rotations will provide more time and others less.
Succeeding on the wards
Unlike the pre-clinical years, success on the wards requires more than academic prowess and high exam scores. Receiving favorable clinical evaluations requires smarts but also the ability to work effectively on a team and interact well with patients – a new aspect to medical school performance compared to the pre-clinical years. It is no secret that students are more likely to receive positive evaluations from attending physicians that they get along with and if they are well-liked by their teams, even if their academic performance may otherwise be less than stellar. Having positive interactions with patients, too, is important: a successful presentation and well-informed clinical care are dependent upon gathering accurate and complete information, and patients are more likely to be open with people they trust and feel comfortable around. Patients who feel especially comfortable with students might occasionally compliment them on rounds to the attending physician, which undoubtedly reflects positively on them. In most cases, attending physicians and residents are less concerned that students answer every question correctly or know every bit of medical knowledge than that students are thorough in their histories and physical exams, thoughtful when formulating diagnostic and treatment plans (even if they are wrong), and helpful in making the team run smoothly whenever possible. It is important to remember that your superiors are also your future coworkers and colleagues, and being hard-working and a team player is just as important as having intelligence.
Beyond clinical evaluations, most medical schools require their students to complete standardized subject exams known as shelf exams for each rotation. These exams are similar in style and content to the Step 2 Clinical Knowledge licensing exam taken during the fourth year and are intended to provide an objective evaluation of students’ clinical knowledge that is relevant to the particular specialty. Though specific grading rubrics vary among schools, performance on the shelf exam is often the primary determinant of students’ final rotation grades in practice. The exam is graded on a relative scale according to the performance of other students nationally, and schools usually provide grades based on your percentile score (e.g., receiving honors might require scoring at the 90th percentile, receiving a high pass at the 80th percentile, etc.). Thus, while clinical performance is important, learning on the wards does not necessarily translate to learning that will be useful for the shelf exam, and students will usually require a substantial amount of outside studying in order to do well. Balancing this somewhat dichotomous relationship takes some practice, and students often don’t get into a studying groove until their second or third rotations.
During the pre-clinical years, I viewed the wards with a sense of mystique and uncertainty but eagerly awaited the opportunity to treat real patients and learn actual clinical medicine. I couldn’t wait to start seeing patients: what I ultimately wanted to do when I dreamed of becoming a physician and before I even applied to medical school. Learning the basic science of biology and human disease was interesting yet unfulfilling in itself. Without an outlet to use that knowledge, I felt like little more than a tape recorder: absorbing knowledge, solidifying that knowledge in my memory, and expressing that knowledge on exams, only to overwrite what I had just learned with still more information.
Starting third year, I was incredibly excited to finally be on the wards. Despite quickly realizing how incompetent and unprepared I was for the realities of clinical medicine, I was eager to learn and loved spending time with patients. As the year trudged on, however, fatigue, stress, and a certain degree of cynicism began to poison the experience, and the latter half of the year consisted largely of slogging through the remaining rotations with the hope of getting some rest and relaxation. I labored incessantly for the betterment of my patients in whatever ways I could, but I felt the stress affecting me and my ability to function outside of the hospital. Fortunately, the learning became easier with time after reaching a “critical mass” of clinical knowledge: with enough exposure, I began to develop an intuition with respect to what needed to be done in order to best treat patients. It is impossible to know everything in medicine, but towards the end of the year I finally began to have confidence in my ability to independently understand a patient’s problem and develop a plan with at least the basic steps of correcting those problems. No longer limited to being a fly on the wall while shadowing or fumbling my way through a checklist of physical exam items, I could finally contribute substantively to the treatment of patients and play a real, if limited, role in their care.
Now that I’ve had the opportunity to reflect on the year, a few points leap to the front of my mind. First, I’m amazed at just how much can be learned over the course of the year and the incomparable difference between my skills as a clinician at the beginning of the year and today. I recently had the opportunity to work with a second year student at a free clinic – the first time I’ve worked with a younger student since being in the hospital – and the stark contrast in our abilities to talk to, examine, and come up with a plan for a patient was astounding. The structure of the third year necessarily engenders a sense of uneasiness, of never quite settling into the field I found myself in on any given rotation, making it difficult to objectively assess my skills. Presented with the opportunity to do so, I’m struck by how far I’ve come in my training and, even more, how much further I have to go in its continuation.
Second, the clerkship year shaped me in a variety of ways through a series of impactful moments, those “critical incidents” mentioned above, which I’m now beginning to realize. I was struck by both the incredibly passionate ways some of the residents and attending physicians treat their patients and the behaviors of others that I will never emulate in my own practice. I’ve seen medicine serve some of its patients well and completely change their lives, while failing others. I had the chance to work on extremely effective teams and surprisingly dysfunctional ones. I’ve shared incredibly intimate moments with patients who placed their confidence in me – rather than other senior members of the team – to treat them well, and I’ve been on the receiving end of verbal abuse by other patients and their families. In little ways, each of these experiences has affected my development as a clinician and who I am as a person. I am, without a doubt, not the same person at the end of the third year as I was at its beginning.
Finally, and perhaps most importantly, the clerkship year confirmed that I made the right choice to become a physician. I didn’t have a strong interest in every field students are required to rotate through, but talking to patients and using clinical knowledge and reasoning to attempt to improve their condition was fundamentally satisfying for me. Despite the long hours and the stress, I still enjoyed the endeavor and its challenges. Working with people at their most vulnerable and in unfathomable situations is difficult and emotionally draining, but seeing the impact medical successes have on others easily outweighs the difficulties of that task. I expect that the remainder of my training in a field that I truly enjoy and have a genuine interest in will be all the more gratifying, if not also more difficult, and I eagerly await the challenges ahead.