No matter what field you are considering, be sure to closely observe the physicians around you and take mental notes on what makes a good doctor. Along the way, you will encounter fantastic physicians who are inspired and compassionate and intelligent. You may also meet some doctors who are bitter, burnt out, alcoholic, or even borderline incompetent. As you encounter this range of individuals, be sure to take note of the key characteristics that you would like to either emulate or avoid as you develop. Imagine the kind of physician you want to be, and take the time to recognize that your experiences and observations right now are actively shaping your own clinical persona.
Finally, if you need a shot of enthusiasm, begin thinking about residency. Pick a field you think you might be interested in and start doing some research. Skip ahead in this book to the sections on picking a specialty and doing residency research to get ideas about resources to draw on. Start perusing the Web pages of various residencies to get a feel for how the system works and what the different programs are like. This will not only serve as valuable education for the very near future when you begin to apply, but it will also make tangible the fact that you will eventually get out of medical school and on to the next level of your training.
BUT FOR NOW, IT’S STILL SCHOOL: REPORTS, GRADES, AND EVALUATIONS
No matter how refreshing it feels to be out of the classroom and into the clinics and wards, you’re still in school, and the work you do will still be evaluated and end up on a transcript. In many ways, your clinical grades and evaluations will be more crucial for your residency application. Most residencies consider the preclinical years to be an important rite of passage, and your success therein rightly or wrongly judged by the USMLE Step 1 Exam. With the Step 1 Exam to handle the didactic portion of medical school, most residency programs tend to focus on the student’s clinical performance as a measure of how well that student will perform as a resident.
In other words, this is your time to shine.
What can you do to optimize your performance? If you follow the strategies outlined above for surviving and thriving in the wards you should be well on your way to getting solid evaluations. This is key, since you will select several of these clinical evaluators to write your letters of recommendation for your residency application.
The actual transcript grade you receive is a little bit tougher to summarize. Some rotations will grade you almost solely on your clinical performance and your presentations. You may be expected to write up a few H & Ps, each a detailed history and physical with an academic differential and a discussion of the problem in the form of a minipaper, usually about two to three pages in length. Many rotations may also require you to take their service exam at the end of the rotation. This is a comprehensive exam produced by the specialty board. The residents may periodically take versions of this exam. They are typically quite hard and broad in scope. The best way to prepare for them is conscientious reading throughout the rotation and a solid specialty-review book designed for medical students. You may be able to track down practice tests, either through fellow students who have already completed the rotation or through your medical-school or university bookstore. Talk to residents to determine what is available at your school.
Overall, one of your best resources for how to survive and thrive in any given rotation will be your classmates who have gone before you. Since each of you will be on your own individual sequence of rotations, there will always be people in your class who have come before you and can give you an insider’s view. Naturally, you have to take anyone’s opinion with a grain of salt, since you may have different skills and weaknesses and thus perform differently in a given rotation. However, these survivors can be an invaluable guide to the lay of the land, to the best attendings and residents, and to the most useful reference resources. Use these people liberally to gather information.
“Unfortunately, I think how you are evaluated on clinical rotations sometimes has more to do with how well your evaluator likes you than how well you perform,” Chris explains. “This is often influenced by what specialty you are going into. Many would agree that if you seem more eager to go into surgery, your surgeon evaluators are more likely to give you a higher grade than those who work just as hard but have communicated a decision about pursuing a different field. Ideally this should have nothing to do with your grade, but the reality is that from time to time, it does.”
CHAPTER 17
Problems in the Wards—and How to Deal with Them
Some minds are like concrete
all mixed up and permanently set.
—UNKNOWN
We hope you’ll sail through your clinical years. Most people find that they really enjoy their clinical rotations and that by the time the fourth year rolls around, making a choice of specialty is surprisingly hard. With that said, some rotations will be inherently less appealing to you, and you may also find that you’re simply less suited to some fields than others. Medicine also attracts strong personalities, and you will likely encounter a person or two along the way, often in the wards, with whom you do not mesh. This can make for some uncomfortable moments or, if left unchecked, for some career-limiting altercations. As such, this chapter aims to provide a few simple suggestions for diffusing conflict in the stressful environment of the wards.
ACT WITH INTEGRITY
First and foremost, always did with integrity. This sounds simple and self-explanatory but may be surprisingly challenging in practice. You will be pushed hard on many of your rotations, and cutting corners, glossing over things, and deflecting responsibility or blame for errors, either due to fatigue or out of fear of humiliation, will be a powerful temptation. Furthermore, for the first time you will be dealing with real patients who have complex personal and medical issues. Many of your patients will be unpleasant, unsavory, and unclean. Some will come seeking narcotics and nothing more. Many will refuse to heed your advice or to come to terms with their illnesses. This will be frustrating and aggravating and will at times push you to the point of anger. Some of your attendings and residents may be abusive, angry, curt, unprofessional, uncaring, or downright negligent. Given the stressful nature of medical practice, you will also almost certainly encounter colleagues with personal and professional problems that they refuse to acknowledge or deal with.
So how, exactly, is one supposed to deal with all of this on top of everything else?
Make integrity your mainstay.
Treat everyone with respect. First and foremost, respect yourself. Stay focused on why you’re there—to learn, to grow, and to help. Never let anyone infringe on your boundaries of decency and respect. If you feel these have been violated, excuse yourself, pull back, and regroup. Second, respect your patients. These are the people you’re here to serve. Even those who are clearly seeking secondary gain or are lost in their own pathology deserve your attention and help. You may not be able to cure or even to help all your patients, but you can always treat them with respect and honesty. Finally, respect those who teach you. Be honest in your work and honest about your limitations. If you don’t understand something, don’t be afraid to say so. Work hard to address any deficiency or confusion, but never feel belittled. You are there to learn, and they are there to teach. It’s as simple as that.
Respect your colleagues on your teams, support them in their struggles, and make sure you’re carrying your load and are ready and willing to jump in when something needs doing. There’s almost always more work than can be accomplished, so any given team member who doesn’t carry his weight will be a further drag on your most precious resource—time.
Do everything in your power to make sure you are not that person.
RESOLVING CONFLICTS WITH ATTENDING PHYSICIANS OR RESIDENTS
Even if you do all of these things and maintain the highest level of integrity, there still may be situations where conflicts arise. You may find yourself at odds with an attending or resident who, no matter how you approach a situation, escalates things, is consistentl
y rude, offensive, or discriminatory, or refuses to teach you with the respect you deserve as a student.
Sometimes, it’s as simple as a misperception that can be nipped in the bud and easily resolved. Sometimes, it’s more than that—and when that happens, you must work hard to defuse such issues on the ward.
Your first approach to resolving such a conflict should be a simple, direct, and honest conversation with the individual. Try to initiate the discussion in a private and nonconfrontational way. Ask the person what it is that upsets them about the way you conduct yourself and for things you can do to improve the situation. Taking this approach can be disarming and can go a long way. Make the person feel listened to. Sometimes your efforts may span several conversations. Be sure to try to implement any reasonable suggestions the person offers to you.
Only after this initial approach fails should you take your concerns to the next level. If your problem is with a team member, go to your attending or senior resident. If it is with an attending, go to the department medical-student coordinator or to your dean. Again, your approach with each of these people should be measured, professional, and nonconfrontational. Be sure to clearly communicate that you tried to resolve the situation directly with the individual involved. Underscore that your goal is to resolve the situation and to optimize your experience on the rotation. Your concerns should be taken seriously and addressed by those in charge.
Understand, however, that by taking the conflict to a superior, you do risk escalating the tension between you and the individual or alienating him or her altogether, and drawing negative attention to yourself as well. Everyone on the wards is busy putting patient care first, and no one wants to have to take time out to resolve petty or unnecessary conflicts. As the old adage goes, “If you try to fight a skunk, you’re going to end up smelling bad.”
Unless the problem involves a truly serious offense like sexual harassment, racism, or bigotry, think carefully before you choose to escalate a conflict on the wards.
If you have particular concerns about how a rotation is going, or if it is a rotation that is especially important to you, it may be worth asking for a midrotation evaluation. This will usuallyjust be an informal verbal review of your progress thus far. A good tactic is to approach your attending and say, “I’m really interested in doing well on this rotation. Can you give me some feedback on how I’m doing or what I could be doing better?” This emphasizes that you’re eager to improve and will give you some specific areas in which to demonstrate improvement and proficiency. This approach will also help prevent you from being ambushed by a poor evaluation at the very end of a rotation you thought was going well.
If you do get ambushed despite this approach, or are otherwise justifiably dissatisfied with a grade or an evaluation, make an appointment to see the attending in charge of the rotation and discuss the situation. Hopefully you can come to terms and shed light on where that evaluator thought your performance was lacking. If it was misperception or miscommunication, talk it through and request to have the evaluation changed.
CHAPTER 18
Core Clinical Rotations
To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.
—SIR WILLIAM OSLER
THIS CHAPTER WILL provide a brief overview of the core clinical rotations. Although there will be significant variability from school to school in the structure and schedule of these rotations, the rotations are fairly universal because they provide the fundamental experiences that will form the foundation of your clinical skills. Heed their lessons, and learn the basics well. Mastery of these skills will allow you to shine in the important elective rotations in your fourth year and will become a cornerstone of your practice.
INTERNAL MEDICINE
Your rotation in internal medicine will be a wellspring of these core skills. This is bread-and-butter stuff. The differentials are broad and the problems often complex. Despite having spent countless hours reading and memorizing the intricacies of human disease, you will be shocked to discover actual pathology before your eyes. Suddenly the clinical relevance of all your toils will snap into focus, and you will curse yourself for not paying better attention as you struggle to recall the details of a given condition.
Don’t worry, this is normal.
All medicine is about pattern recognition. The first time you see a condition, its pattern may be subtle and your eyes, ears, and hands not well tuned. The second time you see it, a light may go on as you recognize signs and symptoms. By the third time, you will be surprised to find diagnoses screaming at you from the earliest encounter with a patient. It is tremendously exciting and rewarding to be able to say, “I know what you have, and I know what we can do to treat it.”
Of course, not all your cases will be straightforward.
Disease can be subtle in its earliest stages, and presentations can be highly variable. This is where you need to develop strong clinical detective skills. You will watch your residents and attendings be equally baffled by patients and their presentations, and you will watch them systematically develop a list of differential diagnoses. Together you will step through this list sequentially and logically, evaluating the possibilities and ordering tests to confirm or exclude various things on the list. You will track the patient’s progress, his exam, his lab and test results, and slowly bring the patient’s picture into focus. You will target your therapies at symptoms, prioritized to address the most dangerous items on the differential list that you must act to protect that patient from immediately. Despite the eons of accumulated wisdom and all the sophistication of modern medicine, you will still encounter cases where no one knows for sure what happened to a patient, only that the person got better or died.
Medicine will forever be a humbling profession.
The basic routine of your rotation in internal medicine is largely described by a basic day on the wards. You may also have time in the outpatient or ambulatory clinic weekly or even daily. This will be a very different experience from the wards, more akin to your early patient experiences in the preclinical years. Most people find clinic somewhat frustrating because you don’t know any of the patients personally and only have a few moments before seeing them to review their chart records and get up to speed on their care to date. Nonetheless, clinic is a good time to understand the differences in ambulatory and hospitalized pathology and to differentiate between patients you safely manage on outpatient status and those you need to admit for stabilization, testing, or comfort. This is also a time to observe your attendings as they interact with established patients with whom they have longitudinal relationships. These longstanding relationships are a major reason many people choose primary care as their field.
Career considerations–internal medicine
Most people who go into internal medicine as a career enjoy its differentials and the broad spectrum of patients that they see and care for. Because internal medicine is an adult specialty, your practice will be more limited in ages than the even broader specialty of family practice. The vast majority of internal medicine physicians, commonly called “internists,” are in private practice. This usually means they have joined a group of other internists to form a basic office practice. They see their patients primarily in the office, and if those patients need to be admitted to the hospital, they will care for them throughout their hospital stays. Internists will usually share call with the other partners in their practice. Call duties will include responding to telephone questions throughout the night and going in to the ER to see any patients from the practice who need admission.
Your options for subspecialization in internal medicine are extremely broad. After completing a basic residency in internal medicine, you can complete an approved fellowship. The range of possible fellowships in internal medicine includes adolescent medicine, allergy and immunology, cardiology, endocrinology, gastroenterology, geriatrics, hematology, infectious disease, neph
rology, oncology, pulmonology and critical care, rheumatology, and sports medicine. Subspecialists obviously have a much more narrowly defined scope of practice. Many of these also focus on a variety of specific procedures, such as cardiac catheterizations, colonoscopies, or dialysis. Similar to primary-care internists, these subspecialists tend to divide their practice between clinic time and hospital time. The income potential for the subspecialists who focus on procedures is generally considerably higher than that of primary-care internists.
An additional option in internal medicine that is growing in popularity is the hospitalist. These are physicians who solely admit and care for patients in the hospital. Many primary-care internists will contract with hospitalists to handle all their admissions and inpatient care. This frees primary-care doctors to focus on their office practice and reduces their after-hours workload considerably. The hospitalists, in turn, don’t have to worry about an office practice, and they have the luxury of essentially working shifts, eliminating the need for regular call.
“I always loved the holistic nature of internal medicine as well as the academic side of it,” Adam recalls. “Internists apply an intellectual approach to patient care that I find very intriguing.”
“I found that what I most enjoyed in all my clerkships were the internal medicine-related aspects of each rotation,” Carolyn explains, “like the management of patients with respiratory, cardiovascular, and neurologic illness during my rotation in the surgical intensive care unit; the pathobiology of malignancies in gynecologic oncology; medical issues in high-risk obstetrics; and the evaluation of altered mental status in psychiatry. I felt like I learned the most on my internal-medicine rotations, and I was attracted to medicine because of its constant intellectual challenge.”
Med School Confidential Page 21