As I said in the first half of this survival guide, third year of medical school is an exciting time. When you start your rotations on the hospital floors, you are no longer a mere book-reading student, you are a member of a patient care team with people depending on you. We gave some advice the first time around on how to excel during your rotation, but there was just too much information to cram into one blog post. Here are some more pearls of wisdom to get you through the transition:
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. 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. 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 time will only grow shorter. 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. In programs both small and large, 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 (i.e., 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 trumps all
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 all as a team to get the work done. 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.