How to succeed In Third Year of Medical School

   When I began my third year of medical school last year, everyone's advice to me was to "show interest". At the time, however, I didn't really understand what that term encompassed. Did I just have to listen to what everyone said and know what was going on with patients? It goes a little further than that. 

     As a third year, your shadowing days are over. This is your time to get your hands dirty, do procedures, talk to patients, write notes, and learn. In certain specialties, however, the residents are so busy, they often neglect students. They may have you following them around doing nothing, which is a really frustrating waste of your time.  However, there are ways to make them notice you and still get a good evaluation. Success doesn't happen accidentally. You have to put your mind to it. Here are a few tips to keep when mind during your clerkships:

1. Be professional: This is the minimum required to do well, but it's still worth mentioning. It implies being on time, doing the assigned reading if given, complying with dress code and behaving respectfully around your colleagues.  While it sounds simple, precisely because it is simple it can affect you significantly if missed. The worst name you can call a medical student is unprofessional. You will not honor a clerkship with the "U" word on your evaluation. Some schools will even make you re-mediate the clerkship.

2- Know everything about your patient: This goes beyond asking all the right questions on an H&P. Know their story, where they're from, who is their support network, insurance status, how long they have had a disease, how was it diagnosed. Know which room number they are in without having to look down at a paper. Attendings will be impressed by this. If they ask a patient-related question, you should have the answer. 

When you're on wards, read notes other health professionals have written on your patients. Whether they are consults, nursing, PT, PCPs, doesn't matter, read it all. Read any new information that pops up on the EHR. Follow-up results from the work-up that has been ordered. Write down all the labs and vitals for that day even if they are normal. The attending does not want to hear "normal" if he/she asks you. They want a number. If you are in clinic read notes from past visits to get acquainted with what has already happened. Patients get annoyed when you ask them questions that can be answered by looking at a chart. If you're in surgery, don't just read about the procedure. Try to find out why they are having it done in the first place. Many surgeons are known for kicking students out of the OR if you are uninformed about who the patient is, and why they are there.

3. Take ownership of your patient: remember that one day you will be a doctor and be responsible for patients. Put it in your mind that patients assigned to you are YOURS. Don't let the resident present for you. Step in in any situation where your patient comes up. Especially rounds. This also implies calling other services to get things moving. Blood cultures pending? Call the lab for a preliminary read. Need to consult another service? Page them yourself. Follow-up with what their plan is. Don't just act as a messenger between the patient and the resident.  Talk to the nurses about how the patient is doing. Make sure the patient understands everything that is going on. Because they are your patient,and it is your responsibility.

4. Come up with your own assessment and plan. This will be hard at the beginning when you don't know enough, but at least take a stab at the basics. If you don't know specifically which antibiotics they will need at least mention that you think the patient needs them. 

When writing in patient progress notes, always ask yourself what are the patient goals for the day and what do they need to be discharged. Don't just copy and paste the plan from the day before. Read through it and change it along the course of the hospital stay.

When in your primary care rotation, keep all of the preventative care in mind and find out if your patient meets criteria for any vaccinations, cancer screening, etc.

 5. Read about diagnosis: You will remember things a lot better if you put a face to a diagnosis you have to study. This part is centered more on the disease than the patient. If, for example, your patient has pancreatitis, read about which criteria for pancreatitis does your patient meet. Are the amylase and lipase elevated? Do they meet ranson's criteria? How severe is the disease? What caused their disease in the first place? What are the complications of the disease? Look at the imaging, labs, past work-up. What are other things on the differential diagnosis? Read about management. How long do they need to stay in the hospital? Does this patient need outpatient follow-up? Learning by doing is the best.

6. Don't just accept a diagnosis. Ask yourself why. Going along with #5, the answer to why is usually hidden in your first and second year education. Why is the potassium low? It has to be going some where. Is the patient peeing it out? Is it inside the cells? Don't just treat with potassium replacement. If you bother asking why, you can possibly find what's really causing the hypokalemia and by correcting that you won't have to replace the potassium anymore. Or the answer can tell you that it will correct on its own. Asking "why" changes your management. And that's what an M.D is all about.

7. Take it to the next step: Once you are staying on top of things, reading on your patients, coming up with differentials and your own plan, you will probably be above average from your classmates. This is still what is expected of you, however. If you want to really impress people, do MORE than what they ask you to do. Or at least do it before they ask you to do it.This is hard to do in rotations that you dislike or that you know you don't want to pursue. If you know you want to pursue it, you have to make sure they remember you. Don't wait until someone asks you  if you want to do the discharge summary, start it yourself. If you already did two admissions, but another one comes along, volunteer to do it anyway. Update the sign out sheet every day; learn how to put orders in; go watch your patient's procedure if they have any. Bring in research studies to share with your team that are relevant to your cases. If you go out of your way to do more than what they expect, you'll be able to ask for a letter of recommendation with confidence that it will be good.

7. Don't be afraid to ask questions: A lot of students are afraid of looking dumb in front of their superiors because we work in a culture where we are expected to know everything. Often enough we feel like we know nothing the more information we learn. But by asking questions you are showing that you are present. That you are thinking about the information given to you in a critical way and you are not just accepting what is told to you. Take advantage of working with people with more experience than you. You can't find every answer you need on google or UptoDate. There are some questions only experience can answer. By asking questions you are also letting your superiors know what your level of knowledge is, that way the know what they can teach you based on what you already know.

8. Never EVER complain. About anything. This is medicine after all. It's hard. You will work long hours, feel tired, hungry, stress/overwhelmed, and sleep deprived all at the same time. This comes with the job. Surgery is the rotation you will want to complain the most, but it is the most important rotation in which you shouldn't. The residents have to do the same as you and more. One time in surgery I had a bad cold, pretty sure I was running a fever. However, my resident was sick as well. And if he had to stay and work, I had to too. I never asked to go home. Our attending knew I was sick, he could have sent me home without me having to ask if he thought I couldn't work. Doctors will be the first ones to tell you to get help if you really need it. If you don't complain, you look like a trouper. If you do, you look like a baby. Your choice.

9. Don't let yourself be intimidated by pimping. Some attendings just ask questions to assess the level of your knowledge so they know what they can teach you . Others like to stimulate discussion and critical thinking. I had an attending who would purposefully pick topics I knew nothing about and then he would encourage me to think about the basic physiology of the body or pathophys of the disease to answer the question. It's natural to feel scared under pressure, but don't let it get the best of you. Attendings will respect you more if you don't let them intimidate you. Strong personalities acknowledge each other.

10. Be confident. Or fake it. This goes along with #9. Don't let your fear show. Speak up. The way you phrase things makes all the difference. It's not the same saying " I think maybe it could be CHF?" than saying "His labs and physical exam point towards CHF". Don't give answers that end with question marks. It shows you're afraid of being wrong and hence you don't commit to a straight response. But one day you will be a resident on-call on nights and your decision without question marks could save a life.

11. Be receptive to feedback. People will tell you how you're doing in the rotation in different ways. We all like to think we are super awesome, but that may not always be the case. You are a student. Of course you have things you need to work on. It is important that when someone gives you feedback, you take it with a good face. Take note of what they point out and improve yourself. Don't try to interrupt them to explain yourself. Just shut up and listen. If you really feel like you need to explain a misunderstanding, phrase it carefully. You don't want to come off as immature and stubborn and stuck in your wrong ways. Improving during a rotation shows you have potential to be a great resident.

I hope this advice can help you in the future. It can all be summarized as "showing interest", as I mentioned before. Like my Internal Medicine Chairman said at the beginning of my third year, "Show up. And do your damn job".

Good Luck.