Attending Advice On Clinical Rotations

Many second years are soon to enter the clinics and wards for the first time come June and July. Dr. Mary Brandt, a Baylor College of Medicine pediatric surgeon who blogs at Wellness Rounds, provides the following advice to medical students starting on clinical rotations:

Don’t sit in the back of the plane.

The basic sciences are important to learn the vocabulary and grammar of medicine.  Clinical rotations are different – it’s where you actually learn to be a physician.   If you use the analogy of learning to fly, in basic sciences you are studying the book on how to fly the plane.  In your clinical rotations you are in the plane, watching and learning from the pilot.  Which means you have to be in the cockpit.  You cannot learn to fly a plane by sitting in the back.

In every situation you encounter in the hospital, imagine that you are “flying the plane.”  When the resident starts to write the admission orders say “Do you mind if I write them and you show me how?”  On your surgery rotation, be in the holding area early and ask the anesthesia resident if he/she will explain how to intubate, show you how to intubate, or even let you try.  When you are writing an admission H&P on a baby in the ER, imagine you are the only doctor who will be seeing that patient.  Let the adrenaline of that thought guide you to the computer to look up more about the condition, how to treat it and what you would do if you were the only person making the decisions.

Yes, you need to be pushy and, yes, sometimes it will backfire.  Be reasonable, but stay engaged. If it’s not an appropriate time to be assertive, stay in the game mentally by asking yourself what they will do next, what you would do if you were making the decisions, or what complication might occur from the decisions being made.  Write down questions you will ask after the smoke clears if it’s not appropriate to ask during a stressful situation.

Know what you are expected to learn before you start.

I am not a fan of “learning objectives”.  If they are done well, they are very helpful, but most people don’t take the time to do them well (or don’t know how to do them).  For the rest of your professional life, you are going to have to define your own learning objectives.  So, in a way, learning how to do it early – during your core rotations – is also part of the skill set you need to know.  (Word of advice, though – even if they are very poorly written, you need to read any objectives you are given and make sure you accomplish them.)

Start with a basic textbook.  You will NOT be responsible for learning all the details in the textbook!  Textbooks are written for residents and practicing physicians.  But – a good textbook will give you an overview of the topics.

The strategy:

1.     Make a list of the topics covered in a general textbook.  There are usually 2-3 good textbooks for every specialty.  Ask other students or residents which one(s) they recommend.  You will probably rotate on sub-specialty services during your core rotation, but don’t get bogged down in looking in sub-specialty textbooks.  Stay with the general textbook.

2.     Plan to skim and make notes on every major topic.  These should be “big picture” notes, not every detail.  If there are 60 chapters in the book and your rotation is 2 months long, you should be shooting for one chapter a day.  Keep track and make sure you get them all covered during the rotation (not after).  When you are done with the rotation, these notes should be all you will need to review for the shelf exam.

3.     Don’t read the chapters in order – read them as you see patients (see below). But, make sure that all the chapters are covered since it’s unlikely you will see patients with every disease in the book.

Practice being professional.

It’s really important to be professional and to be seen as professional in all your interactions.  First of all, it’s the right thing to do.  Secondly, a bad interaction with a nurse on the floor can lead to a poor evaluation by your attending.  Make learning how to behave as a professional one of your learning objectives.  Learn from those around you.  Which residents and attendings are the most professional?  Why?  When you see bad behavior (and you will), think about it – what would you have done differently?

Learn from every single patient you see.

Use every patient to learn about their specific disease.  Even if it’s the 30^th patient with appendicitis you’ve seen you’ll still learn something new.  (or use it to learn about their hypertension instead)

The strategy:

1.     Keep a notebook with an entry for every patient you see.  You can use 3×5 cards, if you prefer.  In fact, many hospitals have 3×5 cards with the patient info available in the patient’s chart for docs to take.

2.     Make yourself read something about every patient you see.  If you haven’t read the textbook chapter on the subject, that’s where you start.  If you have read the textbook, review your notes and read something new (UpToDate or PubMed for example)

3.     Make yourself write down a minimum of 3 things you learned from the patient in your notebook (or on your 3×5 card).

Be the doctor for patients that are assigned to you.

You will be assigned patients to follow during your rotations.  When this happens, make up your mind that you are going to “wear the white coat”.   What if you were the only doctor taking care of Mr. Smith after his surgery?  In addition to reading (see above), ask the residents to help you write all the orders.  Write a daily note and make sure your notes are at the level of the residents (ask them to review and critique your notes).  When a drug is prescribed, know the dose you are giving, the effects of the drug and the potential side effects.  When a x-ray is ordered, be the first person to actually see the image and know the result (and make sure you call the resident as soon as you do!).  Don’t get any information second hand – make sure you see the results and the images yourself.  At any point in time, if the attending asks, you should be able to present your patient as though you are his/her only doctor, which means how they presented, their past history, social issues, test results, procedures performed and how they are doing now.

Prepare for conferences.

Every service has at least one or two weekly teaching conferences.  In most cases, the topic (or cases) are known before the conference.  Ask your residents or attendings the day before the conference for the topics and/or cases that are going to be discussed.  Use the strategy outlined above to prepare e.g. consider these “vicarious” patients and learn from them as if they were a patient assigned to you.

Come early, stay late and keep moving.

Taking care of patients in the hospital is a team sport.  The best medical students become part of the team early and are appreciated and – therefore – taught more.  It’s just human nature and it’s just the way it works.  Don’t brown nose, don’t show off…. just show up.   If there are labs to look up before morning rounds, be there 10 minutes early and look them up for the residents. If you don’t know the answer to a question the best response is “I don’t know, but I’ll find out!” If there is scut work to be done that you can help with, volunteer to help before you go home. Anytime you can, make the residents look good. It’s particularly important not to try to one-up the residents.  You will have more time to read than the residents, so you may actually know more than they do about a specific topic.  But, if the attending asks a question and the resident gets it wrong, don’t correct them in front of the attending.  (Unless it’s a critical issue and you think the patient might suffer in which case you have to speak up!)  Whenever you can, set up the resident to succeed.  “A rising tide floats all boats” – if you help them look good, you will look good and the team will look good. Don’t ever sit in the lounge waiting for someone to come tell you what to do.  There are patients to see, conferences to attend, rounds to do, labs to look up… the hospital never sleeps!

Practice having a balanced life.

Compassion fatigue is a constant threat to practicing physicians.  Taking care of yourself, staying connected to family, friends and the outside work are all critical components of preventing compassion fatigue.  This, too, is a skill you need to learn during your rotations so you can carry it with you into your residency and your practice.

Enjoy!  You are finally a “real” doctor!’’

Your experiences on your clinical rotations will be among the most special of your life. Buy a new journal and take time to jot down the funny and not-so funny occurrences of daily life in the hospital.  You will see some extraordinarily beautiful moments of human life.. and some horrendous examples of what people can do to other people. We all learn to deal with these extremes by telling stories. Write down these stories when you can.  It’s also special to record your “firsts”… the first time you set a fracture or hear a murmur of aortic stenosis will be the only “first time” you have.  It’s a special world you are entering.   You’ll want to remember it by taking notes, recording stories and with pictures of your team and unique sights around the hospital. (No patients, though – remember HIPPA!)

Congratulations! You are well on your way to the privilege and joy of practicing medicine.

Click on over to find more practical and healthful advice from Dr. Brandt at Wellness Rounds