Welcome back to the third year of medical school lectures.
Now today we’re gonna discuss tips for what you do
when you arrive on the first day of the rotation
and we’ll also talk about how to be an amazing third year medical student.
What we’ll actually do is walk you through hour-per-hour,
what you can and should be doing to be an outstanding third year medical student
and also to get the most out of your third year medical school rotation.
So let’s jump right in.
Here’s some tips on what you can do the very first day you start a new rotation.
The first day of a new rotation, frankly, can be awkward and almost intimidating.
It’s, you know, you have a bit of fear.
You’re starting a new team and it’s easy though,
much easy than most students think.
Don’t worry about starting a new team.
Don’t let the intimidation get you because we have tips.
You’re gonna fit right in and you’re gonna have fun.
The key is to remember this.
The people on your team that you’re kind of worried about or anxious to meet
were medical students not too many years ago, so they know your struggle.
When you arrive on the first day, make sure to arrive early for sign out.
Sign out is when the night team signs out or tells the day team the patients they admitted overnight.
Sign out is usually at 6:30 AM.
When you arrive the first day, make sure you arrive a little bit before sign out
so you can find your team and go up to them.
When you find your team introduce yourself to your team.
Be friendly. Be excited to be there.
We talked about this concept as the most important variable for the third year medical student
to master in our previous lecture. What you need to do,
number one before everything else is be friendly, be excited, and be engaged.
What you don’t want to be is to the grumpy guy or girl on the corner
who just sits quietly and no one wants to talk to.
No one wants to work with a reserved and annoying medical student.
Be fun, be engaged. Be someone people want to interact with.
Once you introduce yourself to your team,
hi my name so and so, I’m the third year medical student in the team
can’t wait to get to work or whatever you wanna say.
Then, start actually getting to work.
Don’t just say that. Ask them, okay,
what work needs to be done in the mornings?
What do you guys usually do in the mornings?
Ask these basic questions because it’s a new working environment for you
and every medical team is a little bit different.
What you want to know is what’s the lay of the land?
What do people usually do and then what can you do to help?
What you want to do is come off as a hard worker right off the back.
You want to learn what’s the lay of the land so you can fit right in to the team
and that’s where the overall goal. You as a student becoming a member of the team
is essentially the golden way to success.
Now, over the course of the day what you need to do,
and you can do it in the morning if the time is appropriate,
ask the residents and the intern on your team for their phone numbers
and then you can text them yours.
The reason here is not to kind of, you know, be inappropriate or be rude
but if you can’t find your team during the day or when you need help
you can always text them be like, hey where you guys at?
I’m in the ED, can’t find the team.
Whatever happens being in constant communication always helps
or on the other hand when your team gets an admission they can text you
to notify you that hey we have an admission, come see the patient.
They can kind of keep you in constant contact.
Kind of like a good family or you know friends that are in constant communication.
You being in constant communication with your team is also important.
And let me emphasize that again,
being in constant communication is extremely important with your team.
The worst thing in the world is being a medical student that is difficult to find.
This is very bad.
The worst thing I’ve ever heard someone write on an evaluation of a medical student
was medical student was difficult to find. Always gone.
And the student can make the argument, why they didn't know where to go?
Not an excuse. Get the phone numbers. Always be with your team. Always be connected.
Now, what you should always do though is always pay attention to the work that your team is doing.
See how you can fit in and help the team.
The more work you can do for your residents that means the less work they have to do.
The last work they have to do, they have a better life
and in that case you will look more like an asset to the team. You will be more valuable.
So remember, as a first and second year medical student you were in the classroom setting.
You weren’t necessarily working. You were a student.
But as a third year medical student you’re now in the working environment.
You’re in the hospital. People orients in people’s jobs.
So watch what your team is doing and remember you’re in a working environment.
Watch the work being done and ask yourself, how can I fit in?
Or just ask the resident, hey, what can I do to fit in?
I see you guys were doing this. I wanna be an active member.
And they’ll appreciate that eagerness and they’ll let you ride in.
So let’s discuss a typical day in the life of a third year medical student
and in fact, let’s go through the typical day of a star third year medical student.
Someone that you want to emulate.
Let’s day that you’re on your internal medicine rotation as our example.
We’ll use this third year rotation as an example since it applies to most rotations in medicine
and you’ll probably to be rotating in internal medicine within all medical schools.
So let’s go hour by hour. First thing you gotta do is wake up.
So you probably wake up around 5:00 AM.
Now, if your hospital or university has an electronic medical records system
you can actually sign in from home on your phone or on your computer
and see the patients on your service.
You can see how may admissions came in overnight
and even kinda scan them before you arrive to the hospital.
The point here is just to get a sense of what was admitted.
Did you guys get 10 admissions overnight and you’re gonna be slammed?
Or did you get 1 or 2 and it’s gonna be kind of an easier day?
Now make sure you get to the hospital well before sign out.
Usually sign out is at 6:30 AM in the morning at most hospital.
And remember, sign out is this process or this meeting time we have
between the night team and the day team or the overnight team
signs out the patient that they took care of for you overnight
and tell you any events and they also will sign out the new patients they admitted overnight.
What you need to do in the morning is get there early before sign out,
be there already so you can hear the sign out with your team.
When you received admission, the days that your team is admitting,
make sure to always take a patient or two in the morning.
Ask your resident which patient you can take or if you have one in mind that you want to may take.
The point here, as the overall theme of the third year medical student,
is to be active and engaged.
You never wanna be the student that we have to push to take a new patient.
And I’ll tell you as a personal side note, I’ve had this happen.
I met sign out in the morning. You know, we’re all tired.
The night team wants to go home.
They’re telling us the new patients and my third year medical student is passively listening
and they’re like, uh should I take,
No, no, no, that’s not how you’re gonna do it.
What you’re gonna do is you’re gonna be at the table,
you’re gonna be actively listening to the night team
and you’re gonna be listening to all the patients
and then once they’re done talking you’re gonna tell your resident,
hey, can I take that stroke patient? Can I take that GI colitis patient?
Whatever it is. You wanna be actively taking patients and being engaged
and then we’re gonna be like wow, this kid’s good.
Sure, yeah we would be happy to teach you ‘cause that’s the energy we wanna feel.
We never wanna be someone we have to push to work.
It just slows us down. Once you receive your new patients though,
then go to your work room and read about the new patients that you accepted
and you also need to review your old patients.
For the old patients that you’re caring,
and these are patients that you admitted previously
and they’re still in the service they haven’t been discharged yet,
you kind of well develop your own morning routine.
But the core thing is that you need to review for all your old patients or reviewing overnight events,
the vitals, and lab values.
Go through any new imaging and you also you’re going to go need to see these old patients.
Do a quick history and physicals,
ask then about how they’re doing and kind of assess their progress.
Then, you’ll go through your plan for these old patients and see how you’re changing get today
and will you discharge the patient or not.
All these kind of work with the plan or even going in seeing the patient,
you should discuss with your resident because they might want to do it with you together as a team
or they may want you to do it alone and then come back to them
and they’ll help you give you feedback and then you guys can see them again together.
So talk with your resident. See how they want you to see your old patients.
So that’s the old patients, but for your new patients it’s kind of a different story.
First thing you need to do is read the admission note.
This note is gonna be written by the overnight team.
Also called an H and P note, history and physical,
where it’s gonna have the whole story of the patient,
the physical exam, all the numbers and imaging and laboratory values
and the overnight team’s assessment plan.
You’re goal is to become familiar with the patient’s problems
and then by reading the note that is and then going and seeing the patient and examining them.
What you want to do is make sure read about the patient’s medical problem
and the treatment regimen.
You really should be reading it ‘cause you’re probably to some degree gonna be unsure
or maybe even confused.
And likely, during the rounds when you present in the morning,
the majority of the questions you will be asked by the attending
is going to be regarding your new patient.
That’s the newest member or the newest patient to our team.
It’s new to the attending.
They’re gonna have questions and they’re gonna wanna test you to see
do you know why this patient is here?
Do you understand why we’re treating them?
So it’s going to be a very important that you talk with your resident about this new patient
and discuss the plan together.
Let’s take a quick side not as an example.
If a patient comes in for a urinary tract infection and they have burning with urination,
suprapubic pain. Maybe they became septic, whatever the patient is.
Read a little bit about this medical problem first.
Get familiar with the concept.
You don’t wanna go up to your attending or go up to your resident
or go to see the patient completely clueless.
You should have some basic understanding.
A little bit of a search on the internet will help you if you’re very confused.
And then think about what’s going on.
Think about the treatment plan that the overnight team started.
See if it’s appropriate.
The night as the hours go on things change.
See if the things were still appropriate.
Once you’ve had the chance to think a little bit, then talk to your resident.
Ask them. Would you like me to go see the patient by myself?
Shouldn’t we go see the new patient together?
What’s your routine? When are you available to discuss the plan?
All of these things are important because as a third year student
being in the hospital is very is new to you
and for you to be given the task of seeing a brand new patient by yourself is a little bit unfair.
What is fair is for you to have the guidance of your internal service
help you do this so you can learn and grow.
So don’t be shy.
When you accept new patients this really is the time for you to utilize the people above you.
Your intern or the resident to help you grow.
Don’t be shy, ask for help, be engaged.
So now that you’ve discussed the patient with your intern,
you saw the patient, you read the note.
Now you’re ready to present all of your patients and these are the old patients
and the new patients that you have during attending rounds.
In the next lecture, what we’re going to discuss is how to present a patient effectively
and when the attending gives you feedback though during the rounds and tells you,
oh, add this order or go look that up tomorrow.
What I want you to do during rounds is to write down everything immediately.
When you’re sitting there and presenting the patient,
the attending will likely interrupt you and they may say,
you know what order a urine culture or you know we should get a chest x-ray on that patient.
Write it down immediately.
You’re going to forget, okay?
The key to being a successful medical student and even a successful resident is write everything down.
Don’t rely on your memory.
You’re gonna have too many patients to take care of.
Now, when after you’ve presented patients during rounds
other people are going to be presenting as well.
You can have other medical students on service.
There are gonna be some students that are not co-carried by a medical student
so when other people are presenting during rounds it’s very important that you are engaged
and paying attention. You should really only talk when it’s appropriate.
Don’t interrupt anyone. And really just use your common sense.
This may sound rude, but no one really wants to hear what the third year medical student has to say.
And really, the only time when it’s appropriate to talk is when someone asks you a question directly.
It’s also fair for you to ask questions when you’re curious.
But then, again, have a sense of timing and also use your common sense.
And make sure when you are asking questions you’re asking thoughtful questions.
And I say this because sometimes during rounds,
you know, we’ll be sitting there and I’ll have my senior with me
we’ll have the med student, we'll be presenting to the attending
and then med student will just interrupt with a weird question
or a question that they could easily be asking the resident or me in private.
The med student will be asking now in front of the attending and then me and the senior are like,
oh, God that was so awkward, why did he do that?
You know that’s too basic of a question to ask.
Now, again, you’ll learn what questions are appropriate over time
but again, what I want you to do is use your common sense.
Attending rounds are more formal so speak essentially when you think it’s appropriate
and remember, only speak directly when someone speaks with you ’cause that’s a more appropriate sense.
No one’s really excited to hear what you have to think.
It’s more of a learning opportunity for you, not a discussion point.
Okay, so there are different types of rounds.
You can have what are called table rounds or bedside rounds.
So if your team does table rounds they will seat on a table,
present all the patients verbally,
they’ll kind of just talk with the attending.
They'll see the whole service verbally on paper.
So we set the table and talk about every single one and then we’ll be done.
Then, we’ll all get up and go see the patients.
Now, if you’re giving something called bedside rounds
the entire team will go to the room of every single patient.
Stand outside or inside of the room.
The presentation will occur then and then they'll see the patient immediately.
Whether you do table rounds or bedside rounds, you are going to be seeing patients with your team.
The key here is that you need to be well-behaved.
This is not the time to be joking around, playing on your phone,
laughing loudly with another medical student or someone on your service.
During rounds with your attending you really do need to be professional.
Now, common sense is, you know, quite common now.
When you’re on a service and you can tell it's more casual and the residents are kind of laughing,
you can join the team. Just be normal.
But when it’s not appropriate is when it’s a very formal service or in general people are quiet,
you don’t want to stand out. As the old saying goes, “The tallest nail gets hammered.”
You don’t wanna be hammered. Just blend in to the team. Do what everyone else is doing.
Now, when you guys go to see a patient the attending will enter the room to see the patient
and the rest of the team will also go.
And that’s right five or six people or more will be entering the patient’s room at once all standing there.
What you should do is just be quite in the room and be observant.
And again, you can ask questions while you’re in the room to the attending or you know,
to the patient’s. They could be doing an exam and you could ask,
oh, what did you see there or what was that maneuver you do with your hand?
And that’s perfectly fine.
But again, make sure to ask question to show your curiosity with a good sense of timing
and make sure your questions are thoughtful.
You know, if they’re genuine interest everyone’s gonna be okay with your question.
Just make sure it’s appropriate timing.
You don’t wanna be interrupting the flow of something.
Now, when the attending though is examining the patient or asking the patient questions
will you watch closely, listen carefully, and be engaged.
It’s very noticeable during rounds when a patient is paying attention and engaged
or when they’re not and it’s really quite obvious.
You know, we’ll be in the room the attending will be speaking with the patient
or the attending want to ask us to do something for the patient
and the med students kind of staring off or they’re kind of confused with the weird face on their look.
What you should be doing is paying attention and being actively engaged.
Paying attention whenever the attending is around is extremely important,
you don’t want to look disengaged.
Now, when the attending is speaking with her examining your patient that you’re in charge of
ask your resident beforehand what the attending likes during rounds.
Does the attending like for you to co-examine the patient with them?
Say the attending is listening to the heart sounds,
are you supposed to do it again with them?
So ask your resident and say, hey what does our attending like?
How can I be adapting to them during rounds?
And in that way, because some attendings will want you to be doing the exam with them,
you know they may be listening to the heart and lungs
and they may say hey you know what take a listen here
I want you to hear this there’s a finding or here,
here’s some crackles on the lung or whatever they hear.
The key is ask your resident what does the attending like so you can accommodate
and when you accommodate with the attending likes then you’re gonna get the most out of it.
You’re going to accommodate them, so they’ll give you the most teaching.
Now, once rounds are complete the attending will leave for the day
and then your entire team will go back to the work room to start work.
They’ll go back to writing notes, putting in orders.
Now, during the presentations we gave during rounds to the attending,
the attending likely gave recommendation for each patient.
You know, the attending may have said hey, order these new labs
or order these new imaging for the team
or order a consult or whatever the attending wanted.
This is when the team after rounds will go ahead and place all these orders into the computer,
they'll make the phone calls for consult, the interns will finish and wrap up their notes.
It’s a pretty busy time after rounds.
It’s when the most amount of work is getting done in the smallest amount of time.
What you need to do during this time is be active with your team.
If you were given the responsibility for writing notes,
and I hope you are ‘cause it’s a good exercise,
make sure you do a fantastic job on the notes.
Otherwise, if you’re not writing notes, ask your team how you can help.
Your goal, like always, is not to be a leech and just sit in the corner and you know,
thinking to yourself I’m here to gather information.
No, your goal is to give to the team. Your goal is to help with the day’s work.
And if you can help with the day’s work, make the lives of your residents easier,
you will get the best teaching of all.
Now, we do this you know this work after rounds and in noon time we’ll roll around.
Noon time is when you’ll usually have a lunch time lecture or sometime of academic session.
Lunch is usually provided or you may have to stop by the cafeteria and then you go to the lecture.
This depends on the academic institution and what rotation you’re on.
But during this time if you do have an academic session during lunch, pay attention,
enjoy the food, sit there and listen to the lecture.
Again, be professional. This is not the time though to play on your phone,
be joking around to loudly, or reading a book. It’s extremely rude.
If someone’s providing an academic teaching session to you or a lecture, essentially,
you should be engaged. It’s very rude when we see medical student sitting in the back of the lecture halls
with their ipads, playing on their phone, reading a step book. It’s inappropriate.
When you’re there at the hospital you need to give your energy and focus to what’s being presented.
It’s rude to say, oh, I’m gonna do my own thing.
Not appropriate. So be an active member of the team.
Do what the hospital wants you to do.
Now, afternoon conference the rest of the day really is based what your team needs to get done.
If your team is admitting that day,
then you will need to be available for your team to accept new patients with your residents.
Always let your residents know beforehand
that hey, you know what if you get a new admission text me ‘cause I wanna grab them.
I wanna help out with them.
Again, what you’re doing here is being an engaged member of the team.
You are being a team player.
Now, as the day goes on you may have some down time.
The hospital’s not always 24/7 do this, do that.
There’s, you know, normal quiet time as well.
And if it’s appropriate,
you can use this down time to read or one of the residents or fellows
might actually give you a lecture and that’s a very common thing.
People take down time to learn in the hospital setting
so you can educate yourself by reading or looking something up for a patient
or the more senior members of the team may actually give a lecture to the team.
And the rest of the day, prior to sign out, make sure if you’re admitting,
you’re there to help the admission’s room, they know that comes in.
And if you have other down time, you do reading and learning.
Now, as the day comes to an end, what you’re going to do is work on the sign out.
The sign out is a process by which you prepare information for all the patients on your service
to tell the night service, hey, this is one of our patients.
Here’s why they’re here, here’s what we need you to do over night,
here’s what we need you to watch, and you do that for every single patient.
We call this sign out. Sign out is the work we have to do every single evening
so we can sign out our patients to the night team.
What you need to do is talk with your residents and your interns
about what work needs to be done to prepare the sign out for the night team.
The more you can help the residents with the sign out work,
getting the patients on the list,
writing in all the things that need to be done overnight,
the last work they have to do,
the easier their lives are and the more you look like a rock star as a third year student.
I recommend that you always stay for sign out.
If you’re working well with the residents and they see you’re engaged,
they’ll actually teach you not only how to prepare the sign out
but then how to present the sign out of patients to the night team.
They’ll work with you on how to present resident to resident the nigh team service.
After you’re done signing out, go home and read about your patients.
This really is the golden opportunity for you.
If you saw a patient who came in for an ischemic stroke and TPA was given,
this is the best time to go home and read about indications for TPA,
the different regions of stroke and how does it present
or specifically what type of stroke that that patient have.
Review the imaging findings and review your neuro anatomy.
I think you’ll get it just here.
Whatever the patients you saw that day,
whether they were on your service or you heard about,
whether you were seeing them or the other medical student was seeing,
it’s a great time to learn.
When you can translate the active patient care in the hospital to textbooks that you’re reading,
that information will stick in your mind.
So when you go home don’t just eat, lay there, play on your phone, and go to bed.
Really take an hour or so just to kind of engage yourself and say,
you know what I saw a good patient today.
I should spend 30 minutes to an hour just reading about that.
Then, that reading pays off gold. And once you’re done go to sleep early
because to be frank you’re gonna be waking up again tomorrow and repeating the process the next day.
So let’s summarize what we’ve discussed.
The first day when you start a new rotation, introduce yourself to the team.
Be engaged and collect everyone’s contact information.
You wanna be excited to be there
and you also wanna have everyone’s information to be in constant contact.
Always think to yourself, how can I help with the workflow today?
The more you can help the work getting done in the hospital,
the last work the residents have to do and the more you’re seen as a valuable asset.
Follow the regimen outlined through the third year medical student
hour-per-hour thing that we covered.
It shows you being engaged and that you’re a hardworking medical student.
Make sure to present well to your attending.
Run your presentations by your residents.
They’re happy to help you and make sure to be professional on rounds.
When the attending is around it’s not an appropriate time to be playful or joking.
Always get to the hospital early and always stay late.
You will be recognized as an early arriver and a late leaver
and hard work will always be recognized and you’ll be a star third year medical student.