Tips for MS3 Clerkships

From the CalEMRA MSC Leadership

Chair: Kenneth Kim (UCLA)

Vice Chair: Ellen Kettler (UCSD)

Accessible Text Version

• Research Your Case: If something is interesting about your patient, find a pubmed article on it and tell your team about it during rounds. Seriously, they love it (some attendings will outright assign you to do something like that). When it's your turn to present, just something like "I noticed that his Hep B labs have an interesting pattern and I found an article describing a similar case also in a patient on immunosuppressants." Then if they seem to want to hear, quickly describe the findings. It'll show that you're reading and learning about your patients independently.

• Set Expectations: Particularly for longer rotations, remember that it’s all about how you can build trust with your residents and attendings. Don’t assume intern-level tasks and resident-level abbreviated presentations on the first day after your team changes, even if your old team got used to this before the change. Instead, ask your intern/resident explicitly “hey, this was how my workflow was before. Are you comfortable with that?” This will help you do the same when your team changes almost daily during your 4th year EM sub-is.

• Engage and Be Present: Really engage and be present during the day on wards. Yes, everyone will be stressed about studying for shelfs and some will require more book time than others, but recognizing patterns of symptoms and management choices with certain diseases worked best for me when I was focusing on learning from my patients. The reason I remembered the presentation and management details of congestive heart failure was because I learned from my CHF patients and read up on specific details during the slower afternoons/after I got home from work. It helped me personally way more than trying to do disparate UWorld questions or reading from very detached textbooks.

• Understand the Workflow: Spend the first day or so really just getting familiar with the layout of your physical space and workflow of the team. You’re likely not going to be saving lives on the first day, so don’t stress yourself out that you’re not “impressive” on the first day. Instead, spend day one setting yourself up for success later by knowing how your team works and where the bathrooms are.

• Be a Team Player: Get there early, jump on opportunities to help the team, don’t steal pimping questions, generally be a nice, eager, team player type person and you’ll be fine. Being a “team player” means actively seeking ways to help the team, but also means don’t be a jerk to your fellow med student. Don’t swoop all the cool cases. Don’t try to make them look bad in front of the team. If you’ve answered the last like 10 pimping questions, it can be nice to lay back and give others a chance. I’ve heard of people trading off who gets to answer, but I never did anything that formal with my fellow med students. I just tried to be aware and be conscientious. I've been on teams where a resident or attending directly asked me a question and the other student would jump in and blurt out the answer. Don't be that person.

• Rounding Routine: I recommend getting a rounding template. It simplifies your mornings and makes sure you don’t forget things. Some people print out their progress note and present from that, and that’s totally fine too. While on rounds write down the action items for each patient, especially yours. This will be your “to-do list” when rounds are done. Whether it’s calling a consult, checking for an ultrasound to be read, or an important lab to result.

• Help with "Scut Work": Don’t be afraid to ask to help with "scut work." Yes, sending faxes and calling collateral is no one’s favorite task, but doing things like this on patients you know well shows ownership of patients and helps residents put more and more trust in your court. Also, particularly on surgery, no one will be there to hold your hand and walk you through every task, so be observant and take note of things like what wound change supplies are being used and offer to get them the next day. Obviously don’t only be doing stuff like this, but if you’re shining on your presentations already, don’t be afraid to take the step towards being an intern by doing some of the dirty work.

• Consults: Ask to talk to consults! Yes, some institutions will have meaner consultants than others, but it’s a great way to show initiative and learn something along the way (how to call consults, asking consultants questions you might have). If you’ve never called a consult before, ask your resident to coach you through it! It may be slightly more work for them in the moment, but everyone wins in the end because you’ll be able to call consultants with less of their help in the future. The reason I feel more comfortable calling consults as a 4th year is because a resident took the time to coach me in calling consults while on medicine during 3rd year. A great phrase to use is “for my own education, can I ask you about this?”. Consultants are often fellows who like teaching and would be willing to break stuff down even to med student level.

• Work on your patient presentations: It’s what attendings are going to see of your work, so practice them in the mirror if you have to. No shame. Ask interns/residents to help you practice (not in the morning, though, everyone is busy in the morning).

• Studying for Shelf Exams: Prepare thoroughly for your shelf exams. When I came off Step 1 dedicated, the thought of opening UWorld made me want to vomit, so I delayed preparing for my medicine shelf and it made it way more stressful than it needed to be. At the start of each rotation, you’ll likely be told that your shelf only counts for a small percent, so it might seem like a minor part of your grade. But, a lot of students are going to get stellar evals, so what will end up separating honors, near honors, and pass will frequently be the shelf exam. You definitely have to nail your evals to get honors, so don’t sacrifice good clinical work for studying, but make sure to steadily study every day.

• Anticipate Next Steps: The grand majority of shelf questions are going to be “what is the next step in management,” so I’d recommend focusing on the presentation, work up, and treatment is for major diseases. Yeah, you’ll still get the occasional “what enzyme is broken” type questions, but if I remember correctly, I felt like the majority tested if you could recognize what disease it was and what needed to be done. Whether it’s knowing when to get an MRI vs CT, or which drug is first line, or who needs to go straight to the OR, etc, it’s a lot less pathophys and a lot more management. But it’s still NBME, so there will often be a twist, like a contraindication hidden in the past medical history, or two drugs you shouldn’t prescribe together, so you need to pick the second line treatment instead of the first.

• Trust Yourself: As you get more comfortable with rotations, push yourself to move away from writing EVERYTHING (or maybe even anything) down. I found that the less I used notes, the more fluid and streamlined my presentations became. Trust yourself that you’re asking the right questions and that you’re presenting the most important information when it counts. Obviously if it’s early or you’re still struggling a bit on those presentations, save this for later in the year/rotation.

Recommended Resources:

• IM: Step Up to Medicine, OnlineMedEd, Pocket Medicine

• Family/Ambulatory Medicine: OnlineMedEd, USPSTF Anki deck

• Neurology: Blueprints, Clinical Neuroanatomy Made Ridiculously Simple

• Psychiatry: First Aid for Psychiatry, Lange Q&A

• OBGYN: ACOG UWise Questions, Blueprints

• Surgery: Pestana’s Notes, DeVirgilio’s, Surgical Recall

• Pediatrics: BRS Pediatrics, OnlineMedEd

• Everything: Uworld!

Quick Tips

• Diabetic patient: Always check the last 24 hrs of fingerstick glucoses to see how their glycemic control has been and potentially suggest changes to the insulin dosing.

• Patient with Heart Failure: Get daily weights to monitor his diuresis and strict I's and O's.

• BMs: Always make sure your patient is pooping. Constipation is common in the hospital and many patients need a bowel regimen.

• Telemetry: Check the event record for arrhythmias each morning

Resources for Shelf Exams:

Prioritize UWorld, it’s the best resource. Beyond that, utilize books, videos, and Anki based on how you learn best. Online MedEd is a good resource, and I definitely recommend it. That being said, I have found that it doesn’t go deep enough to answer NBME style questions. But, it is an excellent way to get a framework for the pathophysiology, presentation, diagnosis, and treatment of major diseases. So still use it, but don’t expect it to be enough on it’s own.

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[Included in our Q3 newsletter. Editor: Tiffany Fan]