Though I am two years into my residency, I still experience flashbacks to my time as a medical student on the wards. The adrenaline of arriving at the hospital 2 hours before rounds, scrambling to see my patients, constructing a note that no one would ever look at, and preparing a hastily-constructed presentation to deliver in a half-performance, half-examination outside of our patient’s room.
I remember being the object of a thousand microaggressions, coming from scrub-techs residents, nurses, and (gasp) attendings. I was always standing in the wrong corner, using the wrong computer, or choosing the wrong time or person to ask a question, things I would have gladly changed had I known how to do them right. Medical school seemed like a game, and I never understood the rules. Slowly, through getting fouls and penalties, I learned some of the basics, and being hardworking and earnest, I was able to, at least, get by.
As a resident early in my training, I now have the benefit of seeing medical students from both sides of the MD. I try to share my unsolicited wisdom with students the first day they are on my service. I have committed these lessons to paper, so hopefully, a few more students can understand the game before they are tossed into the ring. In no particular order, here are the rules for my medical students:
1. It’s not about you. Often, the students I work with seem so caught up in proving themselves on the wards, honoring their clerkship and studying for their shelf exam that they forget hospitals exist to take care of patients. While many of us at teaching hospitals are dedicated to the dual mission of patient care and education, ultimately our patients’ safety and lives come first. Students frequently seem surprised when life on the wards does not stop at their arrival: no one is waiting to orient them on their first day or to immediately answer their question the moment it pops in their head. It’s not that we want students to feel lost or confused, sometimes we just don’t have time.
In that vein (pun intended), contact your residents before the clerkships starts so they can carve out a few moments to properly orient you. You’ll get more information through a 3-minute phone call than a 3-hour text exchange. Make sure you have all of the details you need for the first day before you arrive: when and where to meet, and what is expected of you on the first day. This will save you the anxiety of uncertainty, and let your resident orient you when they are not overwhelmed with patient-care tasks. Once you are actually on the wards, ask if it’s a good time for a question before you ask a lengthy question about, say, the pathophysiology of preeclampsia. This shows you understand that there is more going on than just your education, and you’ll be more likely to get a thoughtful answer.
2. Help me help you. I love to teach. In fact, it is one of the great pleasures of my job. Unfortunately, however, when I am managing a service of 20 patients, running in and out of the OR, and trying to stay on top of my charting, sometimes it’s hard to fit in lessons. I always tell my students “help me help you.” If I get my work done, it gives me more time to teach. Helping is not always glamorous, and in fact, may include infamous “scut work” like requesting records, helping move a patient onto the OR table, or taking that disk down to radiology for a repeat read.
My best students are like Oprah’s assistants: They hear the team talking about something needed, and without request, these students make it happen. “Ms. Smith really needs to go back to her endocrinologist” we might mention on rounds. The astute students hangs back after rounds, finds out who her doctor is and makes the appointment before our notes are written. Asking “how can I help you” is good. Figuring out what you can do and doing it is even better, as this demonstrates an understanding of how the team functions.
3. Become the guru. Curiosity becomes a luxury in residency, when clinical duties consume most of the day and looking up clinical questions must be squeezed in between notes and putting in infinite orders for medications and fluids. Great medical students pick up on those clinical questions and become the experts, spending idle moments researching topics for the team. They educate the team, the residents, and even attendings, on topics that are new or outside of usual scope, reviewing the literature and providing concise explanations for clinic situations.
One of my favorite examples of this was during my Gyn-Onc rotation, when a patient with ovarian cancer and symptomatic ascites presented with a cellulitis over her Denver Drain. The drain had provided immense relief, and the team was reluctant to remove it, and even our ID specialist was uncertain about the proper protocol. Unprompted, our student delved into the literature, and did an impromptu 7-minute talk on the different kinds of indwelling drains, the primary literature on superficial vs. systemic infection, and his recommendation based on his findings. We were all grateful for the lesson, more informed, and able to take better care of the patient for his efforts.
4. Know the basics. Ultimately, the job of the medical student is to learn. Each field has its own knowledge base and skills that you are required to master, and the focus should be on that skill set while you’re on clerkship. One useful orienting tool is to think in differentials: what are the main problems patients present within that field, and how do we work through them? While on OB-GYN, I walk students through vaginal bleeding in pregnancy, postpartum complications, and early unlocated pregnancy, just to name a few scenarios. The student should be able to name a few common causes of each of the main complaints in your field, and, at least, more through the initial workup. If I ask you to name one possible cause of third trimester bleeding, and you stare blankly at me, I am going to worry about your knowledge base. If you don’t care enough to read at home, it is hard for me to invest in you as my student: you have to meet me halfway. Learning in differentials, rather than just memorizing the textbook, helps you be ready for clinical (rather than classroom) learning.
I frequently had the experience of blanking when asked any question (including my name), by a superior. Giving yourself mental crutches can help with the panic that frequently comes with being on the wards. For example, when I teach students about non-pregnant vaginal bleeding, I have them move from outside to inside, with infection, trauma, cancer and “PALM COINE” (a common acronym for abnormal uterine bleeding). These terms will catch the majority of causes, and at least, give you a framework on which to form an answer.
5. Know what you don’t know. If you don’t know the answer to a question, please just say so. Making up an answer does not fool anyone. If you have some basic knowledge of the subject, it’s totally reasonable to think through the problem out loud. For example, when asked why the patient is tachycardic, you might say, “well, they do not have a fever, and they just had surgery, so could blood loss could be the cause?” rather than staring blankly or suggesting something outlandish from your Step One study guide like pheochromocytoma. Remember, when you hear hoofbeats, think horses before zebras. However, if you really do not know what kind of ovarian tumor secretes estrogen, it is ok. Go home and read about ovarian tumors, and come back the next day with a well-informed question that shows you did some research.
Try to identify concepts you struggle with so that when asked “what do you want to learn more about” you have an answer. Basic topics in a field are best for this, like, “I want to know more about the treatment of preterm labor”, or “Can we review abdominal entry for laparoscopic surgery?”. The best topic, however, is the one your teacher is prepared to share. Sometimes the best response to this question is: “I would like to know more about x, but if you have a favorite subject to teach, I would love to hear about that.”
6. Master some skills. Every rotation has a few easy procedures that are totally appropriate for medical students. Master these and you can be an awesome asset to the team. Staple removal, doing ultrasounds for the presenting part, or closing laparoscopic ports are just a few examples. Ask to tag along when your resident performs these tasks, and express interest in learning how to do them yourself. Your interest and enthusiasm will be appreciated, and you can take these skills forward to your next rotations and your eventual career.
7. Pay it forward. Remember all of the confusion and anxiety you had on your first day of your clerkship? How great would it have been to have someone explain everything you needed to know from the medical student perspective? You can do that for the person coming on after you. Worried the next person will outshine you, now that you have figured out the system and shared your hard-earned wisdom? Don’t. The best demonstration of your professionalism is preparing your coworker. Plus, if you create a culture of good signouts in your medical school, you’ll never have to show up unprepared again.
8. Be this person. This is the most important of all of these recommendations. Be the kind of person you would want to work with. Days on the wards are often spent in small spaces for extended periods of time. Be considerate, be neat, and be kind. Ask about your coworkers’ weekends, offer to grab water when you go to the nurses station to fill up your bottle. When you print out the article for journal club, print copies for your team. Work is better when you enjoy the people you are with, and when they enjoy working with you.
While medical school can sometimes feel like The Hunger Games, I hope this list helps you navigate your medical rotations with a little more confidence and a little less anxiety. Here’s wishing you a meaningful, educational, and even enjoyable experience!
M. Alexandra Friedman is an obstetrics-gynecology resident.
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