The third year of medical school was the true beginning of my medical education. I still remember turning on my pager, terrified, yet unbelievably excited, to hear that first beep. Gone were the days of didactic lecture. Now, I stepped into actual patient care. The end of course exams no longer carried the same weight. Instead, I would need to impress a team of residents, fellows, and attendings to earn an honors. I was expected to be a contributing team member who showed up on time, knew my patients better than anyone else and established great rapport with them (as well as my teammates), read up on my patients at night, and improve throughout my rotation. In short, I had to prove that I could be a doctor.
As a brand spanking new third year medical student, you’ll learn how to take care of patients, document their progress through well written notes, and manage an entire patient census. You’ll start by learning clinical medicine. At this point, having completed your USMLE Step 1, you should have a strong foundation of knowledge to build upon. Progressing through your third year, you will learn to apply the basic sciences to actual medical management. Then, as a fourth year, your role expands! You will be regarded as an acting intern, responsible for your patients in all facets of their care, from admission to discharge all the way to follow up. As a rising third or fourth year, you’re probably asking yourself how you can possibly handle this level of responsibility. How does one go from lecture hall student to patient advocate as a third year and patient manager as a fourth year? It starts with the 3 A’s that will forever define your role as a physician: Availability, Affability, and Ability.
Your job is to be available. Show up on time. To be prepared for rounds, you should:
- read up on your patients’ progress since you left (overnight MD, RN, PT/OT notes, etc.)
- learn about the new patients added to your team’s list
- review new lab data and vital signs
- see your patients
- start the daily progress note
It sounds like a lot, and it is. Most students need 30-45 minutes per patient to complete all of these tasks. This means that if rounds are scheduled for 7:00am and you have been assigned to follow two patients, you should on plan to arrive by 5:30am at the latest! Try to avoid extended breaks — you want to be available for those urgent consults or codes! Show initiative — always ask to see the new patient, even if they aren't “interesting.” Take responsibility for your patients! Follow their specimens to pathology! Be the first to review images and the first to interpret their labs! Most importantly, don’t ask to leave. Patients are admitted throughout the day, and medical school is your only chance to learn as a student before residency begins in just two short years.
This is simple. Be a cool, hardworking person that the residents, fellows, and attendings want to hang out with and spend time educating. The most important thing is to be kind and genuine with your patients, share in the happiness and embrace them in their sorrows. This can make or break your grade. As a third year on internal medicine, I followed a patient for three weeks with an intestinal carcinoid tumor. I treated him with dignity and respect. I learned that he used to be the life of the party and the friend who others could call in times of need. With time, he had confided in me that his girlfriend left him after learning of his poor prognosis. He trusted me and he believed in my ability (even though he was the first patient of my clinical career). And when we made our rounds with our attending in the morning, he always asked that his doctor disclose the plan for the day. I, a third year medical student, was “his doctor.”
Your ability is measured by the quality of your clinical presentations and written progress notes. Patient presentations should never exceed five minutes for new patients and no more than 1-2 minutes for known patients. It is your job to ascertain the pertinent positives and negatives that your attending looks for in your presentations on the first day of your rotation. Yes, this is a subjective evaluation of your skills, but at the University of Colorado, this subjective form of grading was molded into an objective evaluation by the RIME scale: Reporter, Interpreter, Manager, and Educator.
The Reporter demonstrates the ability to report on knowledge by answering what brought the patient to the hospital, what was found on physical examination, and what was investigated by labs and radiographs.
The Interpreter takes the next step by synthesizing that information into a differential diagnosis and rudimentary plan based on a complete, itemized problem list.
The Manager has a plan in place for not only this encounter, but subsequent encounters as well. The Manager can identify the most likely diagnosis, based on a thorough assessment of the patient’s problems, a full plan including medications, doses, consults, and further objective work up, specific admission and discharge criteria, follow up recommendations, and barriers to continuity of care. Finally, the Educator is the expert whom you turn to when you have identified the limit of your ability.
The Educator is your chief resident, fellow, attending, or consult. A 3rd year medical student should strive to be an Interpreter, while a 4th year medical student should strive to be a Manager. With due time, you will become an Educator.
Clinical rotations represent a strong deviation from the norm of preclinical medical school.
From the moment you put on your white coat in the hospital, you become a doctor and an integral member of your patient care team. The lack of didactic sessions should encourage self directed learning and daily improvement. You should strive each day to take the next step on the RIME scale. Take chances! You are still a student and will have constant oversight and back up from your residents, fellows, and attendings. You will never be alone. And if you show your ability, you will be rewarded with increasing responsibility and autonomy. Be available, be affable, and become able, and you will find success.