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Study Hints Clinical Rotations

Study Hints Clinical Rotations



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Study Hints Clinical Rotations
Study Hints Clinical Rotations

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Published by: MedShare on Sep 26, 2009
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Hints – Clinical RotationsJames Lamberg28Jul2010DO NOT DISTRIBUTE - 1 -
General Tips & Hints (From Clerkship Students)
* Professionalism: Be nice to all hospital staff, including nurses. Bad impressions come back to haunt you.* Misconduct: The #1 issue students have on rotations is failure to follow their Clinical Clerkship Handbook.* Humor: Not everyone has the same sense of humor and although students may use humor as a stress-breaker during pre-clinical education, it likely is not appropriate in the hospital. Any disease that is interesting to a medicalstudent is likely horrible for the patient. Act professionally in these situations and avoid appearing excited.* Drugs & Alcohol: Many hospitals randomly screen students. Some schools even have repercussions for DUIs andother offenses outside of the hospital. You’ve come too far to flush everything over this issue.* Studying: At minimum, buy a clerkship book for each of the core rotations (FM, IM, Surgery, Ob/Gyn, Peds,Psych). Recommendations include the First Aid series, Case Files series, or PreTest series. Other useful books areBoards & Wards and Iserson’s Guide To Getting Into Residency. Carry the ACLS Pocket Cards in your white coat.* Free Stuff: Never complain about anything that was given for free (housing, food, equipment).* Maps: Search online for hospital/parking maps prior to the rotation. Print maps for your white coat pocket.* Traveling: If you will be traveling, get AAA for your car and a GPS device.* Nosocomial Infections: In general, everyone is too busy to pay attention to your hand washing. So make it a habitto wash your hands before and after seeing any patient. Alcohol hand sanitizer will not kill C. diff spores.* Vaccinations: Remain up to date with vaccinations including annual flu shots, not just for yourself but for every patient you come into contact with. Not everyone has the luxury of vaccinations (e.g. immunocompromised).* Gloves: Carry gloves in your pocket, especially on a procedure-heavy rotation (e.g. anesthesia). You may get a lastsecond shot at helping with or performing a procedure. Also helpful: alcohol preps, adhesive bandages.* Needlestick: If you get an accidental needlestick (blood or fluid contaminated) go immediately to the ED.* Procedures: If you are interested in learning/doing procedures, you must ask. You can go through two years of rotations without learning how to do an IV, or you can come out knowing how to perform lumbar punctures,intubation, thoracentesis, paracentesis, etc. If you do not ask, you most likely will not get an opportunity.* Pimp Questions: If there are students already at the rotation site, ask them what type of questions the attending physicians like to ask so you can prepare. Else read about the top 10 most common diseases for that rotation.* Before Rotations: It is a good idea to know how to fully read an ECG and CXR before you start rotations.* Evaluations: Evaluations usually need to be completed by a doctor, not necessarily the site’s attending physician.If you work well with a resident, they may be willing to do your evaluation.* Letters of Recommendation: You will need 3 minimum so ask for letters sooner rather than later.* Sub-I: Rotating at the hospitals you want to end up at is very important, if not crucial, for any residency program* Feelings/Emotions: Put on a very thick skin. Some clinicians do not like teaching or working with students. Someclinicians have abrasive and toxic personalities. Do not let this get to you, just move on. You will also be involved inmajor events in the lives of your patients, some happy, some sad. In general, do not cry in front of your patients.* DNR: If you want to discuss DNR with your patients, read “Discussing Do-Not-Resuscitate Status” by Gunten.* Output = Input: Rotations are what you make of them. Do not expect anyone to teach you except for yourself.
Pocket References & Smart Devices
 Useful Pocket Books
: Maxwell’s Quick Medical Reference, Tarascon Pocket Pharmacopoeia (if you do not have a pocket device), Pocket Medicine: Massachusetts General Hospital Handbook of Internal Medicine
Useful iPhone/iTouch Apps (free)
: Medscape, MedCalc, Skyscape, WikEM, Gas Guide, AHRQ ePSS, NEJM,Prescriber’s Letter, STAT GrowthCharts Lite, Hypermunes Pregnancy Wheel, iRadiology, Eye Handbook, OMMGuide, CPR & Choking, ScoreCenter (to follow your attending’s teams), Textfree Unlimited or textFree.
Useful iPhone/iTouch Apps (not free)
: iFiles, Antibiotic Advisor or EMRA Antibiotic, H&P, ECG Guide, iMurmur,MD On Call, USMLE Wiz, AutoWiFi, iFitness. Save your money on full versions of LEXI, Epocrates, or Skyscape.
 NEJM Videos In Clinical Medicine: http://www.nejm.org/multimedia/videosinclinicalmedicine
--------------------------------------------------------------------------------------------------------------------------------------------Selection Criteria For Residency: National program Directors Survey (Acad Med. 2009; 84:362–367)
: Required clerkship grades > Recommendation letters > USMLE Step 1 score > Grades in senior electives in specialty > Number of clerkship honors > Audition electives > USMLE Step 2 score > Class Rank.
 Least Important 
: Academic awards, published research, grades in preclinical courses, medical school reputation.
Most Competitive
: Plastics, Orthopedics, Otolaryngology, Ophthalmology, Radiology, Rad/Onc, Neurosurgery
: Emergency Medicine, Urology, Dermatology, General Surgery, Anesthesiology, Pediatrics, Ob/Gyn
 Less Competitive
: Psychiatry, Pathology, PM&R, Internal Medicine, Neurology, Family Medicine
Hints – Clinical RotationsJames Lamberg28Jul2010DO NOT DISTRIBUTE - 2 -
Choosing A Career, from EMRA The Medical Student Survival Guide (2nd, Harkin)
You should sincerely love the specialty you choose. You will spend a tremendous amount of time training, and youdeserve to be happy. So, take your time in making the right decision. You should look forward to going to work every day and feel good about the job that you do. Otherwise, it is not fun, and you will not last. Invest in long-termhappiness. Delay some immediate rewards for bigger, better ones down the road after training. You will succeed if you spend the time carefully thinking through your decision for a specialty choice and focus on a balance betweenyour professional and personal goals. Residency is not something you just want to endure...The right specialty for you is right because it makes you happy inside, because it matters to you.
250 Biggest Mistakes Third Year Medical Students Make (2006, Desai & Katta)--------------------------------------------------------------------------------------------------------------------------------------------
 Domains of Unprofessional Behavior: poor reliability and responsibility, poor initiative and motivation, and lack of self-improvement and adaptability. (Teherani, Hodgson, Banach, & Papadakins, Acad Med 2005;80;S17-20)Residency Directors rank “grades in required clerkships” at the most important criterion. (Wagoner & Suriano, AcadMed 1999;74:51-58)Typical Day: Pre-rounds, work rounds, work/morning report, attending rounds, noon conference, work timePre-rounds: Student sees patient alone, goal is to identify new events that occurred the previous day or overnightWork rounds: Team travels to rooms, most junior member updates the team on the patient’s progressAttending rounds: Entire team meets, student-attending interaction mainly occurs here
Commonly Made Mistakes With Evaluations:
 1) Beginning the rotation without a clear sense of what your evaluators are seeking. Per Metheny, residents tendedto place more value on a student’s work ethic, teamwork, motivation, punctuality, interest in the specialty, and patient involvement. Faculty placed more emphasis on the student’s knowledge base.2) Underestimating the importance of specific faculty and resident comments. Clerkship performance is consistentlyranked over preclinical performance and extracurricular activities.3) Glancing over your clerkship evaluation form. As soon as you start a clerkship, look over the evaluation form.Familiarize yourself with the criteria on which you will be evaluated. What descriptors are used to describe top performance in each category?4) Remaining unfamiliar with the goals and objectives of the rotation. Each evaluator will compare your  performance to a certain standard of performance that they have in mind. How can you determine the evaluator’sstandard of performance? In addition to learning about the evaluator’s expectations, ask them to describe what theyconsider an ideal student.5) Not knowing who will be evaluating you. Are evaluations of your clinical performance weighted differently atyour school? In other words, do attending physician evaluations carry more weight than resident evaluations?6) Failing to realize that the team members will talk to one another about your performance. Your evaluators willoften solicit opinions of your performance from other team members. The evaluator will be looking to see if teammembers’ thoughts are consistent with their own. If inconsistent, your evaluators may question their assessment.7) Underestimating the importance of the write-up and oral case presentation in your evaluation. Clinicians may betoo busy to evaluate your history and physical exams. Although some evaluation forms allow the evaluator to mark “not observed,” others may not. Evaluators must then draw conclusions based on other areas of work.8) Performing poorly during an observed history and physical examination.9) Not seeking a mid-rotation feedback meeting.10) Remaining unaware of the factors that can cloud your evaluation. Central tendency: The evaluator rateseveryone as average due to laziness or the desire to not appear too harsh or lenient. Severity bias: Harsh assessmentregardless of performance (“hawk”). Horn effect: One bothersome factor leads to lower ratings across the board for a student. Recency bias: Recent poor performance affects overall rating. Primacy bias: Evaluator is not able to get past the student’s bad start. Contrast bias: Being compared against other students instead of clerkship goals.11) Failing to realize that you may benefit from a rating error. Halo effect: Evaluator is impressed with one aspectand rates student higher overall. Leniency bias: Lenient assessment regardless of performance (“dove”). “Similar ToMe” bias: Student shares something in common so is rated higher. Recency bias: Recent excellent performancemakes up for previous poor performance.12) Underestimating the likeability factor.13) Moving to the next rotation without learning all you can from your previous experience. When you are ready for the attending to write a letter of recommendation, make it as easy as possible for him to write a glowing letter. Asmonths pass by, specific memories of your performance might fade, making it difficult for letter writes to create a
Hints – Clinical RotationsJames Lamberg28Jul2010DO NOT DISTRIBUTE - 3 -letter with specific examples and details that back up the praise. For this reason, with every rotation, keep track of your accomplishments and the compliments you receive.14) Failing to encourage your evaluators to turn in their evaluations. Per Hunt, over 30% of evaluation forms wereturned in more than two months late. If you have impressed an attending physician, you want them to submit anevaluation. You may even expect that this will happen. Unfortunately, when clerkship directors ask evaluators tocomplete and submit evaluation forms, some do and some don’t. To ensure that an evaluator has submitted your evaluation form, check in periodically with your clerkship director.15) Feeling that all is lost after a poor clinical evaluation. Successful grade appeals are the exception rather than therule. However, if you feel that an error was made, you should certainly consider an appeal.
Commonly Made Mistakes With Patients:
16) Harming the patient. You are the team’s expert on your own patients, and therefore you have the ability to prevent and catch medical errors.17) Transmitting a nosocomial infection. The contaminated hands of clinical staff is the most frequent cause of thespread of antibiotic-resistant pathogens.18) Introducing your self inappropriately. One option is saying “Hello, I’m student doctor Lastname,” or better is“Hello, I’m Firstname Lastname. I’m a third year medical student who is part of the team that will be taking care of you while you are here in the hospital. With your permission, I would like to ask you questions related to your medical history.” If a team member introduces you as a “doctor,” clarify your position and role to the patient at theappropriate time. Do so in a way that avoids any embarrassment to the team member.19) Referring to your patient as a disease.20) Forgetting to care. Strive to care for your patients as if they were your mother of father.21) Following a script. Although you may not want to miss any details, following a scripted format impedeseffective interviewing. A patient may say, “I’m so worried about what will happen to my kids if this chemotherapydoesn’t take care of my breast cancer.” As a patient, how would you feel if your physician didn’t bother toacknowledge this statement and moved on to the next question?22) Taking it personally. Hospitalized patients often feel as if they have no control. This is a distressing feeling, onethat you can diminish by keeping your patients well informed of what will happen next.23) Using medical jargon. In your interactions with patients, remember to avoid medical jargon. Don’t use medicalterms such as CHF or COPD.24) Answering the patient’s questions without exercising caution. Take care in answering a patient’s questions. If you give the wrong answer, intentionally or unintentionally, you could create a very difficult situation. If you areeven slightly less than 100% confident, then it’s best to inform the patient that you will return with the answer.25) Putting the team at risk for a lawsuit. Per Beckman et al, communication issues play an important role in a patient’s decision to sue. Four themes are identified: perceived desertion of the patient, delivering information poorly, and either failing to understand the patient perspective or devaluing the patient of family values.26) Spending insufficient time on patient education. Educate your patients on their illness, let them know wherethings stand, what’s in store for them on a particular day, and what they can expect in the long-term.27) Underestimating the importance of including family members. Ask the patient first if they would like to bespoken to alone before the family is involved. Include family members whenever possible.
Commonly Made Mistakes At The Start Of A Rotation:
28) Waiting too long to request time off. Inform all members of your team if you will be absent. Remember, you are part of a team so someone will have to take up the slack when you’re gone.29) Letting the luck of the draw dictate who you will work with. Per University of Michigan Medical School, anattending faculty’s clinical teaching abilities have a direct positive correlation to student NBME exam performance.30) Lacking the equipment to do the job. For all rotations, have a stethoscope and penlight. IM: reflex hammer,tuning fork, visual acuity card, ophthalmoscope. Surgery: scissors, paper tape, kerlix, cover sponges. Pediatrics:ophthalmoscope, otoscope with pneumatic attachment, calculator, reflex hammer, measuring tape, tongue blades,toy (for distracting apprehensive children). Ob/Gyn: reflex hammer, pregnancy wheel, bandage scissors, tape, gauze.Psychiatry: reflex hammer, tuning fork.31) Lacking the necessary books. However, don’t go on a shopping spree if the school/hospital library has books.32) Starting the rotation without talking to students who have recently completed it. Find out in advance the name of the attending physician with whom you will be working. Then check with fellow students to learn more about thisattending. What is their style? How do they like to do things? What are their pet peeves?33) Reading clerkship orientation information after the rotation starts. You want to know what is in store for you.

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