How to succeed in clinical rotations as a medical student
For many medical students, January is a time of transition from the classroom to the clinic. Finally, after all the studying, exams, and shadowing, you will begin your formal clinical education. It’s an exciting time, full of nervous energy and anticipation. You’ve likely been thinking about this transition for many years, and it has finally come. How do you make the most of this opportunity? What will be expected of you? How can you more quickly adapt to the expectations of your medical student role? In this post, I will share my experience starting out in clinical rotations, juggling exam preparation with patient preparation, and finding my rhythm as a competent medical student.
I started my clinical rotations in internal medicine, which gave me a broad overview of how to work in the hospital, the hierarchy of a medical team, and how medical students can contribute value. The hierarchy of a medical team, from bottom to top, is generally as follows: medical student → resident intern → resident physician → chief resident → fellow → attending. As you see, you’re more than a few rungs from the top. This hierarchy determines decision-making, and you will do well to respect its order. The confusing part is that there are many additional team players, especially in hospital medicine, which include: nurses, nurse practitioners, physician assistants, pharmacists, social workers, nutritionists, and more. Medicine is a team sport and being a team player is essential for success. When you learn to provide the team with valuable information and make their jobs easier with the central goal of improving patient outcomes, you are winning as a medical student.
To provide value, learn from the resident intern. These newly minted physicians are closest to your education level and have more experience. Your goal should be to function at the level of an intern. As a medical student, you should aim to be responsible for multiple patients. At first, start with 1–2 patients, make sure you understand the fundamentals of patient care, and work towards increasing to 3–4 patients. Over time, you will become better at managing multiple patients at once. However, critically, it’s always better to serve 2 patients well than 3 patients sub-optimally. Take your time as you build up the base of your skills and responsibilities.
Intake of a new patient
Ask to take the lead on the new patient arriving at the hospital. If you have time, read the patient’s medical history and start developing differential diagnoses based on the information you have. For example, you learn that a 43 y/o male is en route to the hospital with sudden onset chest pain and shortness of breath. You start considering possible causes: cardiac, gastrointestinal, psychiatric, musculoskeletal. What questions should you ask to assess each of these possibilities? What are the most time-sensitive tests that should be ordered? On arrival, go with a resident to see the patient. Ask the resident if you can take the lead in the history taking and physical exam. The resident will make sure all the important information has been gathered, but you should show initiative to be in the hot seat. This is where true learning happens.
Collect a complete history and perform a physical exam. Gather information to narrow your differential diagnoses and determine what information you need to clarify the situation. As a medical student, you need to demonstrate your thought processes and be thorough to consider all possibilities. Given the history, physical exam, and preliminary tests, start to organize your thoughts and prepare to present the patient to the attending physician. The hardest part is knowing which details are extraneous and which are essential. This becomes clear with experience.
When presenting your patient, your aim is to be succinct, precise, and complete. It can be nerve-wracking to present patients to attending physicians. You will get better with practice. Take a deep breath and find balance between a conversational and professional delivery with an organized format. To keep the attending’s attention, communicate with eye contact rather than reading from your notes.
To further the example, if you suspect the patient is suffering from panic attacks, make it clear in your presentation that you considered and ruled out causes of cardiac, pulmonary, GI, and musculoskeletal origin, and provide supporting evidence for your hypothesis.
John is a 43 y/o male with no significant medical history who presents with 1 week of chest pain and shortness of breath after losing his job. The patient reports a “pounding heart” and “feeling like [he] could not breath” while laying in bed unable to sleep. John has not been sleeping well for the past few weeks and currently lives alone. The pain is at the center of the chest, non-radiating, and 6/10 in severity. The pain has occurred once before in the morning shortly after waking a few days ago. The patient is afraid they’re having a heart attack. Patient denies recent trauma, changes in activity level, alcohol and tobacco use, and does not take any medications, but does report smoking marijuana to help with sleep. The patient smoked marijuana earlier this evening. Patient also denies history of anxiety and suicidal ideation.
On the physical exam…the patient appears pale and anxious with sweaty palms. Vital signs show tachycardia with HR of 130, BP is slightly elevated at 140/80, and respirations are normal.
Eyes: pupils are dilated and responsive to light with injected conjunctivae bilaterally.
Mouth: mucous membranes are dry
Heart: tachycardic, without murmurs or rubs
Lungs: clear to auscultation bilaterally.
GI: abdomen is non-distended and soft to palpation
MSK: no tenderness to thoracic palpation and normal range of movement
Troponin was negative
ECG without abnormality
Most likely diagnosis is panic attack, given recent job loss, sudden onset chest pain while sedentary, and recent marijuana use. History, physical exam, negative troponin, and normal ECG make a cardiac cause less likely. Gastro-esophageal reflux disease (GERD) was considered, but seems unlikely in this presentation.
I think we should observe the patient for a few hours until the effects of marijuana intoxication subside and reassess. I think we should hold off on consulting with psychiatry unless the patient’s condition worsens. We should encourage follow-up with primary care and explain how marijuana can exacerbate anxiety. Patient does not have a history of anxiety, so we should also take time to educate them about panic attacks with strategies to manage the physical symptoms.
You want to present a clear picture of the patient and clinical situation to the attending. It is important to be aware of your biases and how they might color your perspective. Medical school exams have conditioned students to jump to conclusions with limited information. For instance, when students hear “a 25 y/o African-American female with shortness of breath…”, the diagnosis of sarcoidosis comes to mind even though this is unlikely. You must think critically to solve clinical problems in patient care.
Moreover, while your delivery in the patient presentation should be succinct, you should also be prepared to elaborate with more information if asked. I encourage you to take a stand on what you think the problem is and what you think should be done to fix it. Don’t be wishy-washy. If you’re wrong, it’s an excellent learning opportunity. Your team is there to support you and help you improve your clinical decision-making. Volunteer to write the patient’s note; you should be more detailed in your note’s documentation than in your presentation to the attending. Make sure to write out your thought processes in detail with supporting evidence.
Rounding on patients
In the morning, arrive early for patient rounds. Aim to arrive earlier than the rest of the medical team so you have ample time to see your patients and start notes before it’s time to present updates. When you first arrive, review the evening’s events, new labs, and the current status for each patient. If you arrive early enough, you can still find the nurse from the night shift and talk in person to ask follow-up questions from the note. Being kind and helpful to the nursing staff is a major key for success. Check on your patients to see how they are feeling and if there are any new developments. The questions you ask will largely depend on why the patient is in the hospital. If a patient had abdominal surgery, for example, you should be assessing if the patient is pooping, peeing, eating, walking, and sleeping as well as their level of pain, present concerns, and readiness to go home.
Prepare to present the patients to your team with recommendations for the day. Ask yourself, “what needs to happen for the patient to be ready to go home?”. Make a plan to facilitate that goal. When you present to the team, provide a clear update about new developments, explain what you think is the most likely source(s) of a patient’s problems, and highlight action items to address each problem that day. Remember, you are responsible for everything with respect to your patient. What are the maintenance IV fluids that will be given for the day? Are there electrolyte abnormalities that should be corrected? Can the patient be advanced from a liquid diet to more solid foods? Should the anticoagulants be adjusted? Who will the patient follow-up with once they leave the hospital? These are all things that you should consider and have a recommendation prepared.
The recommendation and completion of action items for the day takes time to learn. This is why you should be a sponge and learn from the resident intern on your team. If a consult needs to be placed to another team, how is that done? If the team needs records from a previous hospital stay that are missing, how do you obtain those records? How do you check up on the status of blood tests, pathology reports, and imaging studies that have been ordered? Keep in mind that these tasks need to be done by someone, and if you don’t take initiative to contribute to their completion, then that’s a job for another team member. If the job requires you to make phone calls, coordinate consults, or do investigative research, these are all things that you are capable of as a medical student. Don’t wait to be told how you can help. Be proactive in offering your help on specific action items and communicate clearly that you will be responsible for reporting your findings to the team. Excellent communication and reliable execution is important for gaining additional responsibilities. Demonstrate that you are up to the task.
After the team meeting for patient rounds, the hospital day ebbs and flows with activity as different action items are checked off the list. Focus on the priorities and make sure that your patients are updated on the plan for the day. Ensure that both the patients and family members are always informed on the present situation and next steps. Remember that they don’t want to be in the hospital. You’re the person on the medical team with the most time to foster relationships with your patients. When your patient sees you, they should know that you’re on their team and advocating for them.
When do I study and what do I use?
There are two components you should be studying for as a medical student on clinical rotations: 1) the patients on your service and 2) the SHELF clinical exams.
First, the patients. Study the patients’ problems on your service. Even if the patient is not assigned to you, be knowledgeable about how to manage their care, and the pathophysiology of their condition(s). Use UpToDate for learning about clinical problems and for finding literature to supplement your knowledge. I also used a pocketbook with the most common clinical presentations and treatment algorithms for identifying specific questions and recommending treatment plans.
The attending will expect you to be aware of all the patients on the service and will ask you questions accordingly to assess your knowledge. For example, if a patient on your service has heart failure, you should know what is being done to treat it, why this approach is being used, and what alternative strategies could be tried. You should know the main scores and criteria that are used to determine risk, such as HEART score and MELD score (liver). Use MDcalc.com on your phone to have quick access to common clinical scoring criteria. When making recommendations, you can use these scores to provide additional rationale.
However, to prepare for the SHELF exams, you need to study outside of the clinical experience. SHELF exams are specific to each clinical rotation; the major SHELF exams are: internal medicine, surgery, psychiatry, pediatrics, ambulatory care, neurology, and obstetrics & gynecology. For these exams, you should use UWORLD as your central study resource. These exams are similar to the material you will be tested on for the STEP2 board, and they serve as an important part of your overall clinical grade for the rotations.
To succeed on these exams, medical students should develop a disciplined study schedule. After a long day on clinical rotations, be prepared to come home and complete ~40 UWORLD questions for your upcoming SHELF exam. On days off from clinic, you should aim to do ~80 UWORLD questions. Especially for internal medicine, which has more than 1500 questions, you should be consistent with your studying to complete all questions before the exam.
In my experience, textbooks provided me limited value in SHELF preparation. I preferred books such as PreTest, which have additional questions outside of UWORLD. Additional question banks are particularly useful for the psychiatry and pediatrics SHELFS, which have relatively fewer UWORLD questions.
Furthermore, there are certain textbooks that can be useful for learning how to answer common “pimping” questions. Pimping in medical school refers to the questions that attending physicians will randomly ask you to assess your knowledge. For my surgery rotation, I found the book Surgical Recall by Lorne Blackbourne helpful for answering pimping questions.
Imagine you are assisting in the middle of a surgery, and the attending physician asks you, “Med student, do you see this nerve going to the maxilla? Where does it exit the skull?” Part one is knowing that the nerve is the V2 branch of the trigeminal nerve; part two is knowing that it exits that skull via the foramen rotundum (or as I remember it: foramen roTWOdum). This goofy mnemonic was the only reason I could find the correct answer through the anxiety of being put on the spot mid-surgery. You never know what question you will be asked. Sometimes the questions have nothing to do with the surgery or situation. However, answering these questions correctly is a good way to gain the attending physician’s favor.
Clinical grade and evaluations
While your SHELF exam scores provide an objective measure of your clinical prowess, an arguably more important factor is the subjective score and comments provided by your attending physician. Many of these comments make their way into your application for residency programs. There is a huge amount of uncertainty and bias that goes into these subjective scores. It shouldn’t surprise you that students with charm and charisma perform better. There is a social game to be played, and I encourage you to learn the rules. How do you demonstrate preparedness and show professionalism while being a team player and without being annoying? Annoying medical students who gun for high performance are seen through. You should aim to be authentically helpful and be considerate of how your actions impact the team and the patient’s care experience. As long as you’re working hard and treating each experience as a learning opportunity, you will do fine. It helps if you pretend that you’re extroverted, even if you’re not.
I think above all, consistency of preparedness, demonstration of initiative, and enthusiasm for the work are the highest yield actions students can take to receive positive comments. The attending physician will ask the chief resident and resident physicians for input about your performance. How you act when you’re tired of being at the hospital and want to go home will be the moments when the negative comments come to light. Don’t take shortcuts. While there are some residents who will “test” you by telling you to go home early, use your common sense about whether it is an appropriate suggestion. Most residents don’t go for the low shots with these tests. The best residents know that you’re juggling a lot and their offer for you to go home after a long day of work is honest. Make sure there are no loose ends, ask to contribute to specific jobs, and if there is nothing left for the day, take the suggestion to go home, study, exercise, and above all, get some rest.