Medical

The Other Preparations to Make For Clinical Clerkships

The transition to clinical clerkships in medical school comes after two years of lectures, in-class exams, and national board exams. Without a doubt, it is an exciting transition. It is a key stage in the development of a physician, allowing the student to see real patients and to learn from practicing professionals. Clinical rotations requires the student to critically think and to apply the vast amount of information learned in the classroom to new situations. The goal is to learn to come up with a list of differential diagnoses, use the correct confirmatory test, and develop a treatment plan. This is what many students believe will be the bulk of their clinical learning during the third and fourth years. As a result, many students spend most of their time focusing only on the academic preparation for clinical rotations and do not sufficiently prepare themselves to stand out in equally important, but non-academic ways.
While your preceptor, school, and shelf exams mainly assess your medical knowledge, how you conduct yourself, your personality, and your social intelligence are noticed by all hospital staff members, patients, and their families, and are incredibly important to your overall performance. They can push you over the top or they, by themselves, can sink you. Students have been removed from service due to their poor conduct alone, despite good academic and technical performance. These factors were not likely formally taught to you. You will have to actively make opportunities for yourself to notice and to learn them. Once you apply them, you will get the most out of your half-million dollar education and your clerkship experience.
Interprofessional Team-Work
Clinical rotations provide an excellent opportunity to demonstrate your ability to work in an interprofessional team. During your first two years of medical school, you probably did not have many opportunities to interact with students from other health professions. As healthcare becomes more integrated, employers and residency directors are looking for people who can adapt well to working in a team.
“It is important for rotating students to understand the dynamics of the team on their service as early as possible, since it will create more learning opportunities for them,” advised Dr. Wong, an attending surgeon.
Some physicians, nurses, or PAs make themselves more available to working with students and some don’t want to be around students at all. Students are not able to learn everything from the attending physician or even their residents. A substantial amount of learning opportunities come from nurses and physician extenders, such as nurse practitioners and PAs. Working well with non-physician staff can greatly improve your rotation experience and your opportunities to learn many different things, including procedures. Further, as you progress in your training, you will be expected to take on various leadership roles. These roles will have you leading the coordination of a patient’s care with other providers, including nursing and mid-level providers. Understanding how your nursing and physician extender colleagues work can greatly enhance your leadership abilities as a physician, which will help you in all settings of practice. Working in an interdisciplinary team isn’t just knowing what other providers do; it involves being able to navigate through soft and hard levers of power, bureaucracy, and egos.
Interdisciplinary teams are becoming more common, especially in primary care medicine. The most common example is the medical home, where a primary care physician coordinates the care each patient receives from a variety of providers. This structure relies on physicians who are very well acquainted with how other specialties and care providers work and requires the physician to communicate well with other health professionals. Whether you intend to work in primary care or not, being able to work well in an interdisciplinary team will be a positive attribute that employers and employees will appreciate.
Be Prepared to Work
This is nothing new, and most students know that 24 hour call shifts are in their future. However during each rotation, a handful of students seem to have a momentary lapse in memory. It shows in various ways, such as not wanting to volunteer for an extra task, asking to go to lunch when no one else has been excused, or reminding the physicians that your shift is over. These occurrences are more common than one would expect, and residents and attending physicians do not look kindly upon such behavior. Many will be nice and allow you to leave your service, but will make note of it on your evaluation at the end of your rotation or remember it later when you are applying for residency or sub-internships.
On rotations, student should adopt the idea that they benefit every minute they are allowed to stay in their service. If you are proactive and willing to take on new tasks or stay behind to observe an extra procedure, you are getting more exposure to your future profession. Further, if you are rotating at a hospital which has residency programs in which you are interested, showing that extra effort can go a long way.
“I used to come in on weekends even when I didn’t have a shift,” said Alex, an emergency medicine resident. “My USMLE wasn’t as high as I had hoped, but I got the interview and eventually matched into the program. I’m very confident that my extra effort went a long way in giving me that crucial interview.”
Many students get used to the idea that work should be divided evenly among the group. Working with your fellow students, it is definitely a good idea to divide work evenly amongst yourselves. However, extra assignments by the attending or residents do not need to be divided evenly. If a physician asks you specifically to do something, you should be happy to take the task and not try to pass it along for the sake of dividing work equally. The more work you are assigned, the more favorable the impression you are making.
“If you are assigned an extra patient or asked to stay after your shift, it’s a sign that your attending or senior thinks you’re a very capable person and that they trust you,” said Sam, a second year internal medicine resident. “I would not assign extra work to students who I can’t trust to do the job. If something goes wrong, it’s on us–the senior residents–and not the students.” During clerkships, extra work is a privilege and an opportunity to learn. You will make the best impression if you show appreciation for the opportunity. You may get a glowing letter of recommendation for all your efforts, which is better than currency when residency application rolls around.
Miscellaneous Advice
Knowing how to work with an interdisciplinary team and putting in the hard miles during each shift are both important things for which you should prepare. There are other tidbits of wisdom that do not quite fall neatly into the first two categories. These are things that residents have noticed and wish to share with rotating students:
Do not question your attending or senior in front of the patients and their families. This is something that students do not consciously do while rounding and it can happen to even the most dedicated student. It can be due to being a little too overzealous in wanting to know something. A resident said, “A student I rotated with asked her attending if he heard wheezing on auscultation. She interrupted the doctor while he was examining the patient, which slightly threw him off. She didn’t mean to put the attending on the spot and was just looking for validation, but it made everyone uncomfortable, patient and family included. In short, wait until you’re outside of the patient rooms before you ask for any confirmation.”
Do not give your attending an explanation in lieu of admitting fault for something you did wrong or forgot to do. As medical students, you are responsible for a lot and you likely do not have an established routine yet. As a result, you will likely forget to do certain things related to documentation, history taking, or physical examination. If your senior or attending calls you out for missing something, it is best to not give an explanation as to why you missed it; it is better to simply apologize and reassure them that you will be more careful in the future. Anna, a family medicine resident said, “students try really hard to not be wrong. But no matter the reason why something is omitted or not performed, it still isn’t done. Owning up to your mistake demonstrates a level of maturity. Chances are that the attending has heard all the excuses out there.”
Do your best to not have to excuse yourself during rounds. Try to bring snacks in your pocket in case you are running low on energy. Morning rounds can last until the late afternoon depending on the attending physician and some may elect to skip the lunch period. Use the restroom before the start of your morning rounds. Do your best take care of or anticipate things that may make you excuse yourself from service temporarily. If you have to, it is not usually a big deal, but you lose out on important teachings and explanations. The more present you are, the more favorably it looks upon you in general with all of your evaluators.
Conclusion
Clinical clerkships can be a wonderful experience, both educationally and socially. You will learn faster than you have ever learned before. You will make friends and build important professional connections that will last throughout your career. The experiences you have and the impression you make while on rotations will make a large impact on your competitiveness for residency. A big part of your competitiveness is your academic performance. However, the way you conduct yourself during rotations is just as important, if not more so. Program directors have stated during panel discussions that they consider the coachability of a candidate to be the top factor in their evaluation of potential residents. A big part of coachability is being able to work with others, being prepared to work hard, and being ready to make necessary changes that will help you grow. All the above sections address possible ways to help you stand out and make the most of your clinical clerkships.

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AJ Nguyen is a family medicine physician practicing in California. Dr. Nguyen's interests include academic medicine, preventative care, and healthcare education and leadership.   AJ Nguyen is a family medicine physician practicing in California. Dr. Nguyen's interests include academic medicine, preventative care, and healthcare...