I have spent the last four weeks working on the “House Staff” rotation. This is the internal medicine residency’s inpatient hospitalist service. Or Hell, as I like to call it.
The upside to this rotation is that it is a teaching service so there are medical students who rotate through. I really enjoy having the chance to be on the “other side” of this education equation during residency. It is fascinating. I’ve been able to learn some interesting lessons about how medical students can impact the team. More importantly, how a medical student can add value.
This isn’t really a “how to get honors in medicine” type of post. I’m sure I’ll write that one soon but it may be dreadfully boring and probably involve a lot of nonsense about staying late and brown-nosing the senior resident and attending. Right now I’d rather reflect on what my favorite med students do and what I did that seemed to work well. You can learn a lot of medicine while being an asset to the team. Not just some awkward member of a speed walking white coat entourage.
What is the medical student’s purpose?
Any teaching service worth its salt will recognize that the medical student’s primary purpose is to learn. My biggest pet peeve about clinical rotations in med school was how the grading rubric stated that in order to achieve “honors” you had to essentially be operating independently in all aspects of patient care for > 75% of the rotation. I don’t even do that now. If you are capable of this as an MS3, then you don’t need to be in medical school.
There is a lot of pressure put on a new MS3 just stepping onto the wards. The grading is heavily based on a subjective scoring system that means different things to different people. You switch attendings and residents several times over the course of the rotation and everyone has different expectations and rarely explicitly states them. But you have to get “honors” because your residency hopes and dreams depend on it. All the pressure tempts you to focus on looking good rather than figuring out how to take care of patients and gaining experience.
My IM rotation in medical school was 12 weeks long. It was my first rotation of my third year. I had 4 different senior residents during the inpatient phase. My first one was pretty disinterested in teaching me and never gave me feedback. I fumbled my way through presentations and wrote terrible notes for the first two weeks. Then my second senior came on service. He told me “Everyone gets 4’s, but I will tell you if you suck. I’m more interested in helping you get better than coddling you.” This guy was ruthless. But after two weeks under his direction I had made significant progress. My third and fourth seniors had a similar philosophy but were significantly more kind. I figured out that what I needed was a tight feedback loop with lots of opportunity to practice.
Your purpose is to learn. You learn by doing. So, be willing and eager to try things. Even if you aren’t great at it in the beginning, if you keep taking histories, presenting, and writing notes you will be great eventually. It’s your seniors’ and attendings’ jobs to give you feedback and direction.
How do med students add value?
In my short time as an Intern I have crossed paths with some really stellar medical students rotating through the ICU, general surgery, internal medicine, and in the ED. Writing their evaluations gave me the opportunity to reflect on what they did that made them great. Since I rarely used their medical schools’ criteria for grading (because they are always ridiculous) I developed my own grading rubric. I consider a medical student a valuable asset if they accomplish the following:
- Save me time.
- Lighten my work load.
- Don’t slow down the team
- Be teachable.
- Help out however you can.
- Be easy to work with.
Save me time
My first med student was a brand new MS3 on her first rotation. She was assigned some of my patients to follow. One of our patients was Spanish speaking only. The student was a native Spanish speaker. Obviously this was helpful. But she also went above and beyond by volunteering to double back after rounds to spend time educating the patient about what we discussed on rounds to make sure he understood everything. She also found YouTube videos in Spanish that explained his medical conditions and bookmarked them on his phone. She helped me draft discharge instructions explaining how to take his medicines. All of this was on my “to-do” checklist but she helped me take care of it. And she made it better and faster than I could have done by myself. 100 points to Gryffindor.
Another way to save your resident time is to know your patient really well. I have 7-10 patients to round on before 8:30AM. I can’t spend very much time with each patient. When the medical student knows their patient really well, it saves me a lot of chart digging and running up and down 4 flights of stairs. Take advantage of having only a few patients and get to know their history. Take a deep dive into their clinic notes, operative reports, and imaging studies. You can learn a lot about how medical conditions are treated and particularly how complex a persons medical history can be. Ask the questions I’m not going to have time to explore. You’d be surprised how often a medical student finds out about a new sexual partner, medication side effect, or other relevant piece of information that the resident didn’t think to ask about.
Lighten my work load
This is similar to “save me time” but actually represents a more advance level of saving me time. This is more on the level of experienced MS3s to MS4s. Saving me time means you make it easier for me to do a job. Lightening my load means I don’t have to do it at all.
In our ICU we have 3 interns that manage all the patients under one Senior. There is a “soft cap” of 5 patients per intern. Turns out “soft cap” means if you take only 5 patients then you are “soft”. That census grew to 24 patients pretty quick. On my first day I was mentally preparing myself to pre-round and see 8 very complicated patients in less than an hour. Then, suddenly, a bright beam of light came shining through the doorway and a chorus of angels started singing. There stood Sean. An MS4 applying to gen surg with aspirations of becoming a trauma surgeon. It was clear that he had been operating at a high level for a long time. He was happy to take on a handful of patients himself. All we had to do was go over his plans with him before rounds. He was willing to present patients, draft notes, call consults, put in orders and did it all with a smile. Now, I would never expect this from a med student. But it really showed me how valuable a medical student can be. And he gained a ton of experience by being willing to practice all these skills.
New MS3s can also do this. If you pick up new patients and are willing to present them on rounds then you save me from having to present them. The more you do it, the better you get and you allow me to work on putting in orders or getting other tasks done. And that makes me happy.
Don’t slow down the team
It is totally fine for you to be slow. The rest of the team has been in your shoes and they understand. We actually expect it. But there are a few things that you can do to make sure you don’t hold up the work.
Walk fast. If you ever round with an Intern in the morning you might feel like you’re sprinting between patient rooms. Pushing off with your toes at the end of a step lengthens your stride and you will be able to keep up easier. I’m not kidding. Try this. A 5’5” senior resident taught me this as a medical student because I kept having to jog a few paces to catch up with her. I’m 6’3”.
Practice your presentations before rounds. If you have a patient that you are following for multiple days then practice your presentation at home a couple of times. If you are picking up a new patient for the day then you can find a quiet corner or bathroom and practice with your phone timer before rounds. My attention span is extremely limited. So anything longer than 7 minutes feels really long. I know there is tons of variability in what attendings expect in your oral case presentation, but one of the universal truths is that 5-7 minutes is a solid medical student presentation. Hopefully I can give more pointers in a future post about how to whittle down an OCP to a manageable length.
Don’t read the chart for an hour before actually seeing the patient. Set a timer on your phone for 10-15 minutes. When it goes off, just go talk to the patient. A lot of the time you can get most of what you need from the patient anyways.
You should ask questions on rounds, but be cognizant of the fact that the longer rounds takes, the less time the intern(s) have to get stuff done. If you have a lot of questions or don’t quite understand something, make a note of it during rounds and you can always sit down with the senior or attending at the end of rounds to make sure you understand what is going on.
It is so refreshing to have motivated learners around the hospital. Residents love to teach and help people succeed. We feel encouraged to keep teaching when what we say is well received. If I get the sense that you feel like you already know everything then I won’t bother trying to teach you.
Receiving feedback and coaching can be super uncomfortable. But how you respond to it impacts how the rest of the team perceives you. I was a terrible new medical student. But when someone told me how I could be better I would work on it. The highest praise from my medicine rotation as an MS3 came from my ruthless second senior. He wrote “he acted on every piece of feedback he was given and in the end he excelled in his role.” I straight up ugly cried when I read that. We just want to see you do your best and make the effort to improve.
I once had a mentor who’s favorite saying was that “there’s no growth in the comfort zone and no comfort in the growth zone.” That’s why most of the MS3 year is so unpleasant. You grow a so much and figure out how to apply all your preclinical knowledge into real life clinical situations. Just “embrace the suck” of being new at everything and soak up every bit of information you can. Your patients will serve as a mental framework for how to diagnose and treat a variety of diseases. I still remember my first patient with an acute kidney injury. I know exactly what to do every time I see an elevated creatinine because I remember what we did for him.
Help out however you can
A pair of really great medical students rotated on service towards the end of my month on House Staff. They were experienced MS3s that were rounding the corner and about to become MS4s. They really stood out because of their willingness to help out with any task that came up. One of them tracked down a patient in dialysis to try and talk her into staying in the hospital when she wanted to leave AMA. Another volunteered to go perform some OMT on a very difficult patient who was demanding pain medications. They would go through medication lists with patients, call skilled nursing facilities to get records, volunteer to call patient families and update them. They went out of their way to try and contribute. And everyone on the team noticed. Even though a lot of these activities could be viewed as “scut”, they actually made it so we had more time to do some teaching and give feedback about other aspects of the work more focused on the medicine.
Volunteer to look up information on rounds. If someone asks a question that nobody can answer, you should offer to research it during the day and report back what you find. The best medical students anticipate these kinds of things as well. If we had a patient on some weird chemotherapy or new biologic medication I could usually ask the medical student what the common side effects of this med are or what the mechanism of action is. They had already looked it up. It shows your engagement and initiative. And you learn as you do it.
Spend extra time with your patients who are super needy. One of the patients I had as an MS3 constantly complained that nobody paid attention to him and he was “left to rot in bed for hours on end”. I set an alarm on my phone so that I was reminded to go check on him every two hours. This helped the patient feel like the team was present, but allowed the residents to focus on getting all the work done.
Be easy to work with
What I care about most is how easy you are to get along with. If you are a “know-it-all” or high strung person with no sense of humor then it makes for a long shift. If you are on a rotation somewhere you hope to do residency then you should realize that most of what the residents will grade you on is “would I want to be stuck with this person for a 13 hour night shift?”
I’m sure you’ve already noticed that everyone in medicine is super smart. Recognize that in medicine you don’t distinguish yourself by being extraordinarily smart. You distinguish yourself by being kind. More and more I realize that what patients care about is bedside manner. They rave about their doctors who treat them with kindness and will bash the doctor who is brief or abrasive. You can be taught to write a note or present a patient. It’s much harder to teach someone to play nicely with others.
Welcome to the white coat entourage
Just because the service carries on whether or not you show up doesn’t mean you can’t be a contributing member of the team. Your excitement about learning is infectious and it helps us remember why we went into medicine ourselves. You distract my attending so they spend more time teaching you and I get to write my notes faster so I can go home sooner. You definitely have a place on the team and can be a true asset. Keep these things in mind when you start to feel superfluous on the wards. Ask any resident. A medical student can make or break the team.