Med School Confidential

by Robert H Miller

  After a call night, you will sign out to the other members of your team who weren’t on call and go home, usually around noon the following day. You will be exhausted but also fulfilled. Your head will likely be filled with more questions than clarity. Suddenly, your reading will take on a dimension of urgency. Those subtle points you glossed over in the preclinical phase, those arcane details, will come back to you now as you see, touch, hear, and feel pathology in action. You’ll then catch a few hours of sleep, and before you know it you will be back again, prerounding on your patients for the start of another day.

  “Be a team player, and remember that your education is occurring in real time along with a sick patient’s medical care,” Adam says. “The patient comes first. Learning everything you can about your patient is the best education you can get on the wards.”

  DEALING WITH THE CULTURE SHOCK

  The transition to life in the wards may come as a bit of a shock. You’re a long way from the preclinical classroom, and for some this may be your first foray into the professional world. As a preclinical student, you made your own schedule and worked fairly independently as you attended classes, studied, and took exams. On the wards, you will be expected to be an active member of a busy team that is caring for patients. If you fail to carry your weight, if you fail to follow up on tests or to put in orders as instructed, patient care will be compromised. You may feel very unsettled during your first few weeks in the wards, since your supervisors don’t always tell you exactly what to do. If you find yourself lost, or wondering whether you ought to take some action, you should always ask.

  If you are new to working on teams, or new to the professional environment, here are three quick but critical pointers to help you smooth the transition.

  Professionalism

  First, act professionally in all you do. In class you could get away with dressing in torn jeans and T-shirts; you could chew gum, make crass jokes, or show up a few minutes late. On the wards, you are endowed with the respect and responsibilities of a student-doctor, and it is imperative that you act the part. This means dressing neatly and professionally, and treating your patients, team members, and everyone in the hospital professionally and with respect.

  Reliability

  Second, be an active, responsible, and reliable team member. It is sometimes tempting just to shuffle through a rotation and do the minimum required—particularly if you already know the rotation is of limited long-term interest to you. But if you seek out opportunities to get actively involved, you will be impressed with the return on your investment. You’ll find you get additional teaching, the more interesting patients, and perhaps even opportunities to try your hand at important procedures. Maintain a good attitude in all things you do, no matter what the hour. Try to anticipate your patient’s and your resident’s needs, and pave the way ahead for them. If you know the team is going to need to review the patient’s old chest X-rays in light of a new finding, track those films down ahead of time. Most importantly, know your patients and be an advocate for them. Learn everything you can about them and their histories. Spend time talking with them and understanding their illnesses. Do your homework, research their conditions, the most common presentations, the key diagnostic criteria, the most common therapies, and the typical complications.

  Be mindful, however, of the fine line between being an active, professional team member and being a suck-up. It’s great to help out, but it’s not okay to constantly try and prove how smart you are or to brownnose your attendings and residents. Your supervisors are busy people who are there primarily to take care of patients, to learn, and to teach. If you gum up the works with your pandering, grandstanding, or by copping an attitude, you will quickly find yourself isolated. And that’s not where you want to be on the wards.

  Humility

  As in most professions, the best thing you can do as you enter the clinical world and start out in the unfamiliar terrain of the wards is to display humility. Be honest about the limitations of your knowledge and experience. A sincere “I don’t know—can you teach me how to do that?” will go a long way.

  No matter how hard you get pimped, no matter how stupid you feel, remember that your sole purpose on the wards is to learn as much as you can in order to become an experienced and wellrounded clinician.

  The way to succeed in the clinical years is actually very simple:

  Be helpful to the team you are on without being a suck-up.

  Be knowledgeable about what you are supposed to know, and be honest when you have no idea what you are talking about.

  Be fun to work with without being flippant or disrespectful.

  Do not forget that you are paying extremely good money for the educational experience, and while a certain amount of scut work is the price you pay the team for your training, if you are not getting the education you need, you have to be vocal (albeit politically so) about getting it.

  All of the people I know who had difficulties in their clinical years violated one or more of these key principles.

  —Adam

  HOW TO SURVIVE ON THE WARDS

  Although all of this seems overwhelming, you will quickly find yourself getting into the swing of the daily routine on the wards and even into the regular cycles of new rotations and new roles. The key thing to remember on the wards is to keep your head above water and to stay positive. You will have rotations you will like less than others. You will have long and stressful nights. There will be whole seas of clinical information you don’t know, especially when you are put on the spot on rounds. Do everything you can to stay on top of your patients and keep up-to-date on your reading and studying.

  Stay connected to your patients, and focus on learning all you can so that when you’re out on your own, you can draw on these fundamental clinical experiences. Never lose sight of the fact that what to you is another long night of writing admission history and physicals (H & Ps) is to your patients a scary experience of being admitted to the hospital with an illness. Recognize what it is you get to do, appreciate your role in it, and be an advocate for your patients. In the end these are the things that will make all your clinical time gratifying and fulfilling, and make you eager to come back day after day.

  “I can’t remember half of what I learned in my preclinical years,” Pete admits, “but I still can’t encounter disease in the hospital without thinking back to the first patient who taught me about that particular disease, its differential, and its treatment.”

  READING

  Most students are thrilled to be free of the yoke of preclinical classes and out into the relevant world of real clinical medicine. This does not mean, however, that your hours of studying are behind you. You will still be expected to read and study for each rotation you do, and you must continue your vigilant preparation for your board exams.

  The good news is that all your reading and studying will take on an edge of real urgency as you actually see the pathology in your patients. Suddenly you’ll realize you don’t understand the process of congestive heart failure as well as you thought you did, and the vague list of possible treatments you memorized as a second-year isn’t coming to you as you admit a patient with the disease at 2 A.M.

  “I don’t think you can ever read too much, listen to a patient too much, or have too much on your differential diagnosis,” Deb states.

  There are references for you to read and study that will give you the information you need—and finding these sources is the key to studying in the last two years of medical school. Your emphasis now will turn from textbooks and basic science sources to focus on sources emphasizing clinical relevance. For each specialty under the sun there are basic clinical texts that present the fundamentals of that specialty. These are generally good, but they tend to be long and exhaustive and difficult to cover quickly in a few hours on a call night. They also tend to delve more deeply into reviewing the underlying pathology and pathophysiology that, as we mentioned, is not the focus of your current studies. Your
goal here should be finding a source with just enough of a review of the disease process to jog your memory and much more information about diagnosis, treatment, and complications.

  The reference books most commonly used by medical students are the brief, specialty-specific reviews. These have a range of titles that sound like Essentials of Surgery or Essentials of Obstetrics and Gynecology. Your best bet is to peruse the amazon.com Web site or your med school’s bookstore and find one that appeals to you. The formats for these types of review books vary broadly, so pick one that you find intuitive and appealing and go with it. Most are arranged either as a topic-by-topic review or as a series of topicoriented questions. This latter format lends itself well to being prepared for the tough pimp questions when you’re in your fourth hour of holding the retractor in the OR and the surgeon asks you to name all the encapsulated organisms that pose particular risk to patients who have undergone a splenectomy (an actual pimp question that Dr. Bissell bombed . . . but you can rest assured he went home and read up on it!).

  A reference should be made here to the generic clinical references as well. There are basic, fundamental skills and tasks that are universal to most specialties. Things like what orders need to be included in any basic admission or how to calculate a patient’s ideal body weight for drug dosing. To this end, there are a large number of basic clinical reference texts designed to fit in your pocket and be frantically consulted when you’re sitting in front of the computer admitting a patient. Again, formats vary widely, so it will be pretty much up to you to find one you find easy and concise. You will probably find these books very helpful during the first few rotations and then less frequently relied on as you develop more clinical acumen. (Consult the appendix on page 271 for a list of several of the most popular standard references.)

  Finally, many students use the ubiquitous personal digital assistant (PDA) as their quick reference of choice. With today’s technological advancements, you can pretty much hold an entire reference library in your hand. There is a seemingly infinite variety of tools, calculators, and programs for your education and entertainment. This is a constantly evolving arena, so you will do best to search the Internet and find out what’s currently available and most popular. Many of the titles are available as free or low-cost shareware. Talk to your senior students and residents as well to solicit their informed opinions as to what they found to be most useful (again, see the appendix for a list of some of the most popular resources).

  BASIC CLINICAL SKILLS

  The Foundations of Doctoring course you took at some point during your first two years of med school should have given you some of the basic clinical skills you will now draw on in the wards. Many find, however, that this introduction seems paltry when faced with your first patient and your first real hospital admission. Don’t panic! Use your handy pocket references and these pointers and you’ll breeze your way through the first of many admissions.

  Interviewing and physical-exam skills

  It is normal to feel somewhat bewildered and befuddled as you get ready to approach your first patient. There are a couple of keys to making this encounter smoother. First, arm yourself with a checklist of what you need to accomplish. Your goal here is twofold: first, you need to get to know the patient, understand his or her condition, and begin thinking about treatment; second, you need to suecinctly record all the pertinent data you collect into the patient’s chart so that others can draw on your complete history and physical. So until taking an H & P gets to be automatic, you’ll be wise to go into the room with a template document labeled with the key information you need to acquire. This list should include headings for:

  Chief complaint

  History of present illness

  Review of systems

  Medications

  Allergies

  Past medical history

  Past surgical history

  Family history

  Social history

  Physical exam

  Second, spend time talking to patients before you examine them. This will allow you to develop a relationship with them and put them at greater ease. Strive to make it a conversation rather than an interrogation. Be friendly, conversational, and direct. Try to project confidence without being cocky. When you begin performing the actual exam, be methodical and cover all the bases. You will see your residents and attendings cutting corners and hitting only the high points of an exam, but at this stage you should err on the side of being more thorough.

  Third, as you examine the patient, consider questions that you missed during your interview. Keep a running dialog during the exam. This will put your patient at ease and allow you to fill in any gaps left during the interview portion of your consult.

  Making chart entries

  Once you’ve completed your detailed interview and exam, it’s time to record the data in the chart for everyone to see and refer to. As you write out your H & P, recall that the chart is both the primary means of communication among care providers as well as the very critical legal record of the patient’s care. As such, all your entries should be clear, legible, concise, and professional.

  Any chart entry should begin with the date and time and type of chart entry you are making. It should also include who is making the entry. Thus your H & P might read: “03/15 @ 2100—Admission H & P, Orange Team, (MSIV).” This tells everyone what kind of entry it is, what team it’s going on, and who did the entry. Other chart entries you make will include:

  Daily progress notes

  Procedure notes

  Event notes

  Transfer or discharge summaries

  Discharge instructions

  The proper format for each of these chart entries can be found in any of the reference books listed above. These entries will feel foreign at first but will quickly become a matter of routine.

  Calling consultants and other services

  One of your jobs as a medical student may be calling other services for consultations on your patient. This can be a daunting task since you are representing your service to another team or even another attending directly. Again, your approach here should be to be clear and concise. Instead of launching into the patient’s entire medical history leading up to this admission, start the conversation by stating what it is you need: “I have a sixty-five-year-old woman who presented with a heart attack and now seems to be in renal failure. We would like to get a renal consult, please.” Then, if further background is requested, you can launch into the specifics of the case. Better to give the consulting individual the relevant general principles of the case and save the details for specific questions. More than likely all they’re looking for is the patient’s name, room number, and basic problem. They’ll uncover the rest for themselves as they review the chart and meet the patient.

  Working with nurses and other team members

  Part of the reason many of us went into medicine is because, well, you get to be “The Doctor.” Let’s face it, it’s a bit of an ego trip. You know—the whole “God Complex” thing. It’s both exhilarating and scary to be the final authority on something as important as someone’s health care. What you’ll quickly discover, however, is that health care is 100 percent a team sport. You cannot render care in a vacuum, and if you are so filled with hubris as to believe that only your opinion and insight matters, you will have a short and most unpleasant career in medicine.

  You will be astounded by how much you have to learn from your health-care colleagues, and how wonderfully symbiotic your working relationship can be. Treat your team members with ultimate respect and be open to learning from them. Many, if not most, have been doing this for much longer than you have. Consider their perspective and insights.

  KEEPING PERSPECTIVE AND DEVELOPING YOUR CLINICAL PERSONA

  As with every stage of your medical training, it will be challenging at times to maintain your balance and perspective during your clinical rotations. In many ways, though, this is the most crucial time for you to keep your
eye on the ball. Not only will you shortly be faced with deciding what specialty to pursue, your clinical grades and evaluations will also be a major factor in your residency application, especially in your core rotations. It’s worth doing what it takes to keep yourself focused, excited, and on task.

  One of the best things to do is to seek a mentor. As you go along, you may start to have some inkling of what specialties suit you. Consider seeking out a professor you particularly like, or an attending whose style resonated with you, and set up some time to talk with that person. Solicit that person’s advice on how to become a competitive candidate for a residency in that field, and understand the path your mentor took to get to his or her present position. Mentorship needn’t be a binding contract—you can just be curious and interested in gaining more information and insight. Most people respond very well to someone else showing interest in what they do, and they will go out of their way to discuss their field with you and arrange opportunities for you to get involved or get more exposure.

  Along that same line, consider joining the local interest group for the specialty you’re exploring. Most schools have organized groups dedicated to specific specialties. The groups meet periodically, coordinate extra learning opportunities, and may have intermittent guest speakers. It’s great to get together with other students who are contemplating the same specialty to discuss the details.