Your basic science coursework is complete! So you’re pretty much a doctor now, right? On paper, you know everything that there is to know to pass Step 1, and that’s what it takes to be a doctor... on paper…
All of a sudden, the third year of med school rolls around, and it is GO time. You are starting your clerkships and caring for real patients! No longer will you be in a lecture-driven study bubble. No longer will your clinical exposure be limited to the occasional standardized patient or student-run clinic visit. You will treat real people with real illnesses every day, and in doing so, you will build the foundation of the rest of your career.
Without further ado, here is your survival guide to your first (and future) rotations:
Appreciate the fact that as a doctor-in-training, you are doing something with meaning.
When you are studying to simply advance your knowledge, it is inherently a selfish act. Sure, you are doing it because you have the desire to help fellow human beings in need. But until rotations start, you are helping yourself first. You have been told since day one of medical school that you need a high Step 1 score (or a passing score starting in January 2022!) to get into the residency program of your dreams, so most of your time during the preclinical years will be spent exclusively working toward that goal to ensure your own success in the match.
But when clerkships start, a beautiful thing happens. You are utilizing your knowledge to heal someone. Whether you believe it or not, you are an integral part of a patient’s care team.
As a medical student, because you have fewer demands on your time than a resident, you might be called upon to spend an extended amount of time with a patient in need. It might be you who is changing a patient’s daily dressing, or explaining to them the importance of avoiding excess sodium intake.
Be patient when time slows down or things seem wasteful on rotation.
Most of the time, it is wonderful to be the medical student on the team (constant learning and no true liability!), but sometimes it can feel miserable. I always try to look for the best in things, but I would be lying if I told you you that you could get through all of medical school without a single bad day.
For example, while I was scrubbed into an 8-hour lysis of adhesions procedure, leaving was not an option, but neither was participating in the surgery due to its complexity. I was left standing there, hands gently folded on top of the drapes, trying occasionally to force some small talk with the attending and resident who seemed to have forgotten I was there. It felt more like being held in captivity than a potential learning opportunity.
Some days, your work will be done at 2 pm, but you won’t start rounds until 6 pm, when your attending has finished with clinic for the day. Accept the fact that rotations will not always be a non-stop adventure and do what you can to utilize down-time wisely.
Also, don’t forget the oft-repeated saying in medicine: “Eat when you can, sleep when you can, pee when you can.” Don’t forget to take care of your basic needs when there aren’t any tasks that need your immediate attention!
Recognize that common things are common!
Remember when your biochemistry professor was drawing amino acid structures as he explained the pathophysiology of maple syrup urine disease? Or the time you had to pin down that enzyme that was missing for each of the mucopolysaccharidoses?
You asked yourself, “When am I ever going to have to know this?” While the unique nature of these disorders may be emphasized on USMLE exams, you are much more likely to encounter a case of run-of-the-mill heart failure than you will an atrial myxoma.
Build your familiarity and knowledge of the common diagnoses that you will encounter on your rotations. If neurology is your first rotation, wrap your brain around strokes and multiple sclerosis. If you start on OB/GYN, figure out your vaginitides (vaginitises?), basic physiologic changes of pregnancy, and pelvic inflammatory disease.
For surgery, get familiar with hernias, gallbladder disease, and small bowel obstructions. When your attending asks for a differential diagnosis, always remember the phrase “if you hear hoofbeats, think of horses, not zebras.” This means that you should always try to list the most common diagnoses (“horses”) first before diving into rare diseases or “zebras.”
Know EVERYTHING you can about your patient.
While your resident is likely carrying a census of 4-10 patients, you will probably be responsible for 1 or 2. It is essential that you know everything that there is to know about your patient! If you had no other responsibility as a student, this would be it.
When you are doing your initial history and physical, get down deep and ask even the questions that seem superfluous. Know your patient’s lab values and how they are trending. Know the patient's physical exam and how it has changed since yesterday. Is the type and screen expiring? Did the chest X-Ray get an official read? Did the patient throw up last night? What time did the patient spike a fever?
How can you possibly remember all of this information? It’s simple: Write it down.
A chief resident told me there were two types of interns: those whom he can trust, and those who don’t write things down. The same holds true for students. While you don’t want your patient presentations to read directly from your notes, you should at least have the information in an easily referenced place so that when someone asks for a hemoglobin or urine output, you can quickly fire off the answer.
When the attending wants information and the resident doesn’t have it, your resident might appreciate it if you bail them out (just don’t ever try to show them up or make them look bad!). Your job is to back up your resident and advocate for your patients at all times.
Medical students are also in the unique position of being able to spend significantly more time with patients, and will often uncover pieces of information that the residents might miss because they are too busy doing more time-sensitive tasks.
If you take the time to get to know your patients, they may confide in you that they would really like a phone call to be made to their daughter, or that they need help walking to the bathroom, or that they would love a pair of extra hospital socks.
As a medical student with a bit more time on your hands, you are well-equipped to help them with some of these things, and this goes a long way in terms of patient satisfaction. Showing patients that you care and helping them with these simple requests will be very well received by your entire team!
Never outshine the master (or, don't be a jerk on rounds).
I’ve borrowed this concept from Robert Greene’s brilliant book, The 48 Laws of Power. When we are rounding, there is always an ego-driven desire to show off what we know.
While it is important to demonstrate that you have the required knowledge, you have to be somewhat tactful in the way you answer questions. Be sure not to put anyone down or make anyone look stupid — especially your superiors (which is everyone else on the team).
Remember, everyone makes mistakes and it’s impossible to know everything, so do not embarrass someone in front of a group of peers. If you must correct a person, do it in a constructive, helpful way. If your fellow student doesn’t know the answer to a question, don’t scream it out as though it were obvious and never throw someone else under the bus just to get ahead. In short, don’t be a jerk.
Develop good habits early.
At the start of your rotations, you will set the pieces in motion that will determine how you work throughout your residency and career. During this foundational time, you should strive to develop great habits both inside and outside of work.
Find the time to exercise now, as your free time will only become more limited and precious. Get your stuff organized the night before you have to go in, as everything is easier at 9:30 pm than it is at 5:30 am. Write excellent notes. Do thorough physical exams. Get the full report from your patient’s overnight nurse. Think about it — if you start out with disorganized notes, incomplete exams, and don’t keep up with nightly reading, you will constantly be playing catch-up. Get ahead early.
Build your reputation.
Reputation means a lot in the medical field. It won’t be long before attendings and residents have expectations about working with you based upon what they’ve been told.
If you carry the reputation of being a hard worker and team player, everything you do will appear that much better. If you have a reputation for being selfish or only giving 70%, every day will be an uphill battle. Your successes will appear lucky, and anything you do that is subpar will further cement your poor reputation. Do what it takes (work hard) to develop a solid reputation EARLY ON, from day 1 of starting rotations.
Don't expect to be home by a certain time.
On rotations, schedules are less predictable than they are during your basic science years. Instead of going home at 4pm when lecture concludes, your team will likely adopt more of a “go home when the work is done” mentality.
Sometimes you can’t finish your work until a patient’s medical records get faxed from the outside hospital. Sometimes that late afternoon surgery is more technically challenging than expected, and you are captive in the OR until 8pm.
Your work schedule will be much harder to predict, and trying to plan around it will be an uphill battle. If you think your day will end at 6 pm, your mentality and effectiveness will probably go down the tubes at 6:01. Expect to stick around until the work is done, whenever that might be.
Differential diagnosis — the holy grail
Sometime during your first two years, professors or clinicians probably mentioned the importance of a differential diagnosis. Sadly, these are hard to assemble before you familiarize yourself with the items that populate a differential: the diseases!
After you have spent a bulk of time learning your pathophysiology and you are ready for clinical medicine, it is time to switch gears in your mind, and return to the thought process of forming a differential diagnosis. A good differential diagnosis will guide every clinical decision you make for your patient.
It will steer your review of systems questions to narrow down your broad list. It will point towards the parts of the physical exam that need special attention, and it will direct the lab tests and imaging that you choose to order. Coming up with an excellent differential from the moment you have a patient with “chest pain” or “altered mental status,” and thinking within this framework will streamline and clarify clinical medicine.
Teamwork makes the dream work
When you move on from basic science to clinical medicine, you are essentially switching from a solo sport to a team sport. You and your team will have a lot of patients and a heavy workload, and it is up to you to get the work done together. Help each other out! If a classmate is struggling with the flow of rounds or understanding a particular pathophysiology, take a minute and share your knowledge. Go the extra mile to make your resident’s life easier. Don’t shy away from work. If you have a “me first” mentality, you are doing it wrong. Be remembered as the student who worked well with others; be the student that the team could depend on. Everyone will appreciate it, and the days will be infinitely more enjoyable.
Combine a positive attitude with hard work, the desire to help both patients and peers, and a thirst for knowledge, and your clerkships will be fun and rewarding.