How to Shine on Clerkships: One Gal's Advice

Starting clerkship year is tough for a number of reasons; it isn’t always clear what your role is, it’s hard to know what your team expects of you, there can be pressure to “perform” so that people know that you’re trying - and all of that can really get in the way of optimizing your learning and connecting to your patients, which is the stuff that matters most.

I’m conflicted about giving advice. It’s important to take everything people say with a grain of salt, and my experiences may not reflect yours one bit. Don’t take anything I say too seriously (please!). Still, I wanted to write this because I know I would have loved reading it this time last year.



It’s all about the plan.
This wasn’t clear to me at first. On my H&Ps, I really wanted to flesh out histories and do a thorough exam, I’d (literally) spend hours writing out my thinking in my assessments and then, all tired out from my massive history, make a few lil suggestions for a plan. Which is fine if you’re starting out! But if you wanna get to that “manager” or “educator” (whatever the heck that means, I don’t think anyone knows) level, you gotta put your nickel down.

I started writing my notes backwards. Write assessment first - what do I actually think is going on and why? What are the most likely causes of this and what makes x more likely than y? Then I brainstorm a list of things that I want us to do so we can better understand the underlying pathology and treat the patient’s symptoms. And then I triage - what items are the most important/urgent part of the plan and should be discussed on rounds? Then I go back to the top of the note and fill in the history and physical that support the story that my assessment is trying to tell - the assessment should not be a surprise ending! In fact, your listeners should have to do the absolute least amount of thinking while listening to your presentation because you are elegantly guiding them to the answer (this takes time, be patient with yourself!). But NO new information in the A&P - all of the pieces of evidence need to be placed in their designated spots of the history and physical/labs/imaging. But since you’ve already written your assessment... you know the pertinent positives and negatives (i.e. her chest pain feels like pressure and improves with rest, there’s a family history of heart attacks, she has a 50 pack year smoking history) so your subjective and objective sections of the presentations are all set!

(Also your note is not the same as your presentation. Presentations should have the most relevant information to that day, the whole art of medicine is figuring out what that is, so be gentle with yourself if it takes you time (it will). Your note can have everything under the sun! Defer to your team about their preferences on presentations and notes, just know that not everything you write needs to be said out loud.)

(Semi related pearl that my amazing site director Dr Wheeler told us - every day, review all the objective data and think about every little thing that’s abnormal. That K is a smidge low? Think about your differential and what would be most likely for that patient and what you’d do about it. Do this for everything! A lot of times, it won’t come up on rounds but it’s such good learning ... and if your team does ask you about it, you’ll shine so bright because you’ve already done the thinking!)

Being plan-driven doesn’t just show up in presentations. When you get a new lab value or a new image or a new piece of history back on a patient and you update your resident, give them a plan too to show that you’re thinking. Even if that plan is to do nothing! (“The K came back at 3.4, I wouldn’t replete at this time but if it’s lower than 3, tomorrow we should.”)

In my experience, asking “what can I help with” when you’re being earnest makes it sound like you just want to go home. This is another time to put on your plan hat, throw a suggestion or two - “I just finished xyz task you assigned me. Do you want me to check in on Mrs. XYZ or touch base with the consultants because we haven't heard from them yet today? Or is there something else I can do to be helpful?”. This goes right into my next point -


Be proactive.
Keep your feelers out for tasks that you can help with when you first join a team. Some of them are gonna be easy and you can do them on your own (like checking in on how a patient feels after a new medication or procedure, chart reviewing a complicated patient’s old records), some you'll need to have someone show you how to do for the first time (it might be something like updating the handoff or updating primary teams on your consult recommendations in the morning). Be ready to do those things every day! It really does move patient care forward.

Another way to be proactive is that before you start the rotation, find someone that you trust who’s done it at that site. It might be a peer or someone in the year ahead and ask for a phone call or coffee date. Ask them what little things they did to help move patient care forward, what the role and expectations looked like, what your day to day responsibilities were. There might be helpful templates they can send you (I really only used templates for OB/GYN, the psych review of systems was helpful to have too but it doesn't hurt to have extras in your inbox). These conversations definitely helped me hit the ground running.

One more proactive move I’d recommend is reading up on common procedures for your rotation (i.e. delivering the placenta on OB/GYN, lumbar puncture on neuro, one and two handed knot tying on surgery, IV/endotracheal tube placement on anesthesia) right at the start of the rotation. There’s tons of great videos online and articles with detailed step by step instructions, you can also easily practice knot tying and sutures are home. I’d recommend watching someone do the procedure on a real patient once - and if you’ve read up on all the steps, then you could be ready to give it a try the second time this procedure comes up! Ask your resident if it would be a good set up for a med student to try for the first time. Sometimes it’s not and it’s better to watch again than to put a patient through a lot of trouble because you weren’t the right fit. Of course ask for the patient‘s consent too. (Note- getting a procedure right on a patient the first try feels amazing but it’s ... mostly luck. Of course be proud and excited when it goes well but sometimes it takes multiple tries before you get the hang of it and that’s okay too, you learn the steps better with each try so keep your head up. It takes a whole residency before are truly proficient in procedures, and even then there’s room to grow.)

Be independent.
Okay obvi this is not for procedures, like most third year advice, it conflicts with what I said earlier and is entirely dependent on the context you’re in.

When your resident or attending gives you a task, try a least a few times to troubleshoot before you go back empty handed. If you aren’t sure how to get in touch with someone, call the operator to get in touch with a department or search PagerBox for a specific person. If you can’t find a supply that your patient needs, put on your puppy dog med student face and ask a nurse on the floor if they have time to help you with a quick question. But if you’re really not comfortable with a task (like dressing a wound for the first time might be an example), it’s better to be honest with your team and ask if they can walk it through with you once so you can do it independently next time.


Ask questions!
In all this helping with tasks, don’t forget that you’re a student who is here to to learn as much as you want!

Some caveats though. If you can google your question and easily find an answer (“What’s a normal potassium level?”), google and don’t ask your team. After you’ve googled (and by that I actually mean read UpToDate), ask a next level question like “I’ve heard conflicting things about the cut-off for repleting potassium, how do you usually approach it and what patient characteristics make you especially nervous about a low potassium?”). If you’re on rounds, ask your intern between presentations when you’re walking to the next room. If you’re in the OR and you notice it takes the surgeon more than 60 seconds to answer your question, then wait for surgery to cool down a smidge. Keep a lil journal of your questions (if you’re not scrubbed in) and go home and read up on them. Come back the next day with next-level questions to start some fun discussions with the team!

Look for the learning points.
There will be times you’re just sent to do an endless list of tasks and it feels like no one cares about your learning, your residents aren’t responding well to your questions and there’s little dedicated didactic time.

We know so little as med students though that there is always something to learn. Sometimes it can be a real challenge to find the learning point - but I believe that there is always one there.

On my trauma surgery rotation, we had an endless list of tertiary exams to do, basically patients who had been examined thoroughly in the emergency department with a primary and secondary survey who needed one more check before we could discharge them. It never seemed to change anyone’s management and it felt like some residents could care less so I picked up that it was just a red tape box to check. So at first it felt like it wasn’t “surgery” yknow but then I did one - and it’s a head to toe physical exam which is chock FULL of learning for me!

If you get tasked to communicate with a consultant, you can ask them questions about their thinking to pick their brain. The radiologists were SO nice about this, I’d bop along down to the basement and they’d walk me through scans happily.

Go into every task with an open mind and you’ll find something!


Enjoy not having responsibilities.
Being an MS3 can be maddening because sometimes it is SO unclear what your role is... but it’s also beautiful because often you don’t have an official role with real responsibilities.

It doesn’t always feel this way but what that means is you have the gift of time. Your afternoons are the most free they’ll ever be in your training so you can carve out the experience you want.

One of the highlights of the year was circling back to check on patients during the day. Sometimes there was a change to their disease course or treatment, sometimes we’d just chat about terrible hospital food or their lives. I never knew what to expect but having your eyes on your patients often, it gives you a better sense of their conditions' trajectories and who they are as people, what they value and how they approach problems. It’s invaluable and your team will expect you to know your patients better than anyone else on the team knows them.

Also don’t pressure yourself to carry too many patients! Giving yourself time to really take care of two super complicated patients and dive into their histories is better for you and better for them than trying to juggle three or four.

As an MS3, you have no reason to rush or take shortcuts. Do a full physical exam, ask the whole list of questions and pay extra attention to parts that are special to the rotation you’re on (like the neuro exam or how to take an ob/gyn history). You might never get such a deep dive into that area again. Part of being able to pick up on abnormal physical exam findings is having seen dozens of normal ones to compare it to!


Study efficiently.
By now, you already know how you study best. We are lucky that our shelf scores don’t mean anything as long as we passed so I didn’t feel a tremendous amount of pressure. 

I’d recommend reading at least one resource (ask around, it varies but tried and true are Step Up for medicine, First Aid for the Wards for psych) and doing all the uworld questions for that block. Download the uworld app to your phone and do questions when you’re waiting in line or sitting on a shuttle. If you’re commuting, there’s great podcasts out there, Clinical Problem Solvers is super high yield (you can also just search your patient’s chief complaint on the main podcast page and it’ll find something relevant to listen to).

After a certain point in the evening, I opted for an extra hour of sleep than getting 10 more questions in. Everyone is different but don’t be hard on yourself if you’re tired, you’ve had long days and it’s okay if they catch up to you! You can make up for questions on the weekend!


Ask for feedback.
Perhaps one of the most important things you can do.

There might be things you didn’t realize you were doing well that your team is impressed by. Having someone articulate that is validating in the moment and it’s helpful for the rest of your training.

And there will be things you do that need improvement. Inevitably! You don't walk onto the wards day one already perfect - and that's okay! It's actually the whole point of clerkships being a full year. Constructive feedback might sting a little at first (that's normal) but this is your year to figure out how to function on the wards so that when you get real responsibilities, you'll know what to do. The stakes are low right now! Once you get that feedback, try your best to implement it so no one has to tell you twice; sometimes, you don't work with that person long enough for them to see your change but when they do see it, it looks a lot like growth. (And sometimes the next attending gives you the exact opposite feedback! C'est la vie.) Specific, concrete feedback is a gift and I’m beyond thankful to the people who put an effort to give that to me. It’s made me better.

But dang y’all, feedback is hard to ask for!! At first I was hesitant to ask because I didn’t want to impose on my busy attendings and residents time. And then sometimes what they said was vague and not actionable. Everyone will be different in how they give your feedback but there are a few things you can do to optimize the situation.

At the start of a rotation (first or second day), sit down with your senior resident and/or attending and have some concrete goals in mind that you would love for them to chime in on (big is good here- I want to get really good at my neuro exam or I want to be able to tell who’s “sick” and “not sick”). Then every day, have 1-2 little goals and tell people you want feedback before you do it. Before you present on rounds, tell the team “I’d love feedback on how to improve including pertinent positives and negatives on the labs” or before you go into the patient’s room, “Can you watch me do the pulmonary exam and give me feedback?”. The more specific your question, the more specific your feedback. If you work with someone for more than a week, try to touch base in the middle of your time together; it sucks when you get valuable feedback on something you could have improved when your time on the service is over. At the end of the rotation, ask what you need to do to be a good sub I (if you’re trying to sub I in that field) or what you can do to step your game up to the next level. 

A note on evals. Constructive feedback on the evaluation should not be a surprise. Your residents and attendings should talk that through in person. If you get an evaluation that's downright horrid and feels personal (I got one), you have your coach and the site director available to you. At the start of the year, I put a lot of stock in my evals, I knew they didn't *matter* since we had no grades but I still wanted them to look good yknow? But then, people who said I was doing great left me mediocre evals, residents I worked with closely never filled them out, everyone seemed to have different definitions of what the numbers 3, 3.5, and 4 meant. It's easy to get bogged down by the disappointing evaluations and there are other better measures to assess your growth (being able to do a targeted history and physical, defending your reasoning and plan to the team, taking ownership over a consult question, speaking up in didactics or conference, feeling connected with your patients - the list goes on, you decide what matters to you!). Here's what I've noticed about evals, hard work isn't always recognized in every moment but over the course of a whole year, the numbers and comments even out. Some evaluators end up giving you a lot of credit, some don't, but if you average it all together, at least I felt like my evaluations were fair.


Take care of yourself.
It’s hard, especially if you live far away from family, don’t have a close social support system outside of medicine, or are unpartnered. This year is full good stuff, and if you’re burnt out from both ends, it can be hard to appreciate. Third year is a marathon so pace yourself. It looks different for everyone but things that really kept my cup full were working out almost every morning, meal prepping good food on my day off, sleeping 7-8 hours most nights, journaling, keeping in touch frequently with a smaller circle of friends, and calling my parents. I tried to keep my cup full so that I wasn't ever running on empty... but we're all human and it happens so try try to be kind to yourself. Know what works for you and make those things a priority. Third year can be isolating in a number of ways so seek out and cultivate relationships where you feel comfortable and safe talking about the stuff that’s weighing you down and also the stuff that’s made you proud and happy and grateful.


I hope that’s helpful, and if not I'd still love to hear your take. What other tips do folks have for third year?




xoxo,
Juhi