Study Hints Clinical Rotations

Hints – Clinical Rotations

James Lamberg

28Jul2010

General Tips & Hints (From Clerkship Students) * Professionalism: Be nice to all hospital staff, including nurses. Bad impressions come back to haunt you. * Misconduct: The #1 issue students have on rotations is failure to follow their Clinical Clerkship Handbook. * Humor: Not everyone has the same sense of humor and although students may use humor as a stress-breaker during pre-clinical education, it likely is not appropriate in the hospital. Any disease that is interesting to a medical student is likely horrible for the patient. Act professionally in these situations and avoid appearing excited. * Drugs & Alcohol: Many hospitals randomly screen students. Some schools even have repercussions for DUIs and other offenses outside of the hospital. You’ve come too far to flush everything over this issue. * Studying: At minimum, buy a clerkship book for each of the core rotations (FM, IM, Surgery, Ob/Gyn, Peds, Psych). Recommendations include the First Aid series, Case Files series, or PreTest series. Other useful books are Boards & Wards and Iserson’s Guide To Getting Into Residency. Carry the ACLS Pocket Cards in your white coat. * Free Stuff: Never complain about anything that was given for free (housing, food, equipment). * Maps: Search online for hospital/parking maps prior to the rotation. Print maps for your white coat pocket. * Traveling: If you will be traveling, get AAA for your car and a GPS device. * Nosocomial Infections: In general, everyone is too busy to pay attention to your hand washing. So make it a habit to wash your hands before and after seeing any patient. Alcohol hand sanitizer will not kill C. diff spores. * Vaccinations: Remain up to date with vaccinations including annual flu shots, not just for yourself but for every patient you come into contact with. Not everyone has the luxury of vaccinations (e.g. immunocompromised). * Gloves: Carry gloves in your pocket, especially on a procedure-heavy rotation (e.g. anesthesia). You may get a last second shot at helping with or performing a procedure. Also helpful: alcohol preps, adhesive bandages. * Needlestick: If you get an accidental needlestick (blood or fluid contaminated) go immediately to the ED. * Procedures: If you are interested in learning/doing procedures, you must ask. You can go through two years of rotations without learning how to do an IV, or you can come out knowing how to perform lumbar punctures, intubation, thoracentesis, paracentesis, etc. If you do not ask, you most likely will not get an opportunity. * Pimp Questions: If there are students already at the rotation site, ask them what type of questions the attending physicians like to ask so you can prepare. Else read about the top 10 most common diseases for that rotation. * Before Rotations: It is a good idea to know how to fully read an ECG and CXR before you start rotations. * Evaluations: Evaluations usually need to be completed by a doctor, not necessarily the site’s attending physician. If you work well with a resident, they may be willing to do your evaluation. * Letters of Recommendation: You will need 3 minimum so ask for letters sooner rather than later. * Sub-I: Rotating at the hospitals you want to end up at is very important, if not crucial, for any residency program * Feelings/Emotions: Put on a very thick skin. Some clinicians do not like teaching or working with students. Some clinicians have abrasive and toxic personalities. Do not let this get to you, just move on. You will also be involved in major events in the lives of your patients, some happy, some sad. In general, do not cry in front of your patients. * DNR: If you want to discuss DNR with your patients, read “Discussing Do-Not-Resuscitate Status” by Gunten. * Output = Input: Rotations are what you make of them. Do not expect anyone to teach you except for yourself. -------------------------------------------------------------------------------------------------------------------------------------------Pocket References & Smart Devices Useful Pocket Books: Maxwell’s Quick Medical Reference, Tarascon Pocket Pharmacopoeia (if you do not have a pocket device), Pocket Medicine: Massachusetts General Hospital Handbook of Internal Medicine Useful iPhone/iTouch Apps (free): Medscape, MedCalc, Skyscape, WikEM, Gas Guide, AHRQ ePSS, NEJM, Prescriber’s Letter, STAT GrowthCharts Lite, Hypermunes Pregnancy Wheel, iRadiology, Eye Handbook, OMM Guide, CPR & Choking, ScoreCenter (to follow your attending’s teams), Textfree Unlimited or textFree. Useful iPhone/iTouch Apps (not free): iFiles, Antibiotic Advisor or EMRA Antibiotic, H&P, ECG Guide, iMurmur, MD On Call, USMLE Wiz, AutoWiFi, iFitness. Save your money on full versions of LEXI, Epocrates, or Skyscape. -------------------------------------------------------------------------------------------------------------------------------------------Procedures: NEJM Videos In Clinical Medicine: http://www.nejm.org/multimedia/videosinclinicalmedicine -------------------------------------------------------------------------------------------------------------------------------------------Selection Criteria For Residency: National program Directors Survey (Acad Med. 2009; 84:362–367) Importance: Required clerkship grades > Recommendation letters > USMLE Step 1 score > Grades in senior electives in specialty > Number of clerkship honors > Audition electives > USMLE Step 2 score > Class Rank. Least Important: Academic awards, published research, grades in preclinical courses, medical school reputation. Most Competitive: Plastics, Orthopedics, Otolaryngology, Ophthalmology, Radiology, Rad/Onc, Neurosurgery Competitive: Emergency Medicine, Urology, Dermatology, General Surgery, Anesthesiology, Pediatrics, Ob/Gyn Less Competitive: Psychiatry, Pathology, PM&R, Internal Medicine, Neurology, Family Medicine --------------------------------------------------------------------------------------------------------------------------------------------

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Hints – Clinical Rotations

James Lamberg

28Jul2010

Choosing A Career, from EMRA The Medical Student Survival Guide (2nd, Harkin) You should sincerely love the specialty you choose. You will spend a tremendous amount of time training, and you deserve to be happy. So, take your time in making the right decision. You should look forward to going to work every day and feel good about the job that you do. Otherwise, it is not fun, and you will not last. Invest in long-term happiness. Delay some immediate rewards for bigger, better ones down the road after training. You will succeed if you spend the time carefully thinking through your decision for a specialty choice and focus on a balance between your professional and personal goals. Residency is not something you just want to endure...The right specialty for you is right because it makes you happy inside, because it matters to you. -------------------------------------------------------------------------------------------------------------------------------------------250 Biggest Mistakes Third Year Medical Students Make (2006, Desai & Katta) -------------------------------------------------------------------------------------------------------------------------------------------Domains of Unprofessional Behavior: poor reliability and responsibility, poor initiative and motivation, and lack of self-improvement and adaptability. (Teherani, Hodgson, Banach, & Papadakins, Acad Med 2005;80;S17-20) Residency Directors rank “grades in required clerkships” at the most important criterion. (Wagoner & Suriano, Acad Med 1999;74:51-58) Typical Day: Pre-rounds, work rounds, work/morning report, attending rounds, noon conference, work time Pre-rounds: Student sees patient alone, goal is to identify new events that occurred the previous day or overnight Work rounds: Team travels to rooms, most junior member updates the team on the patient’s progress Attending rounds: Entire team meets, student-attending interaction mainly occurs here -------------------------------------------------------------------------------------------------------------------------------------------Commonly Made Mistakes With Evaluations: 1) Beginning the rotation without a clear sense of what your evaluators are seeking. Per Metheny, residents tended to place more value on a student’s work ethic, teamwork, motivation, punctuality, interest in the specialty, and patient involvement. Faculty placed more emphasis on the student’s knowledge base. 2) Underestimating the importance of specific faculty and resident comments. Clerkship performance is consistently ranked over preclinical performance and extracurricular activities. 3) Glancing over your clerkship evaluation form. As soon as you start a clerkship, look over the evaluation form. Familiarize yourself with the criteria on which you will be evaluated. What descriptors are used to describe top performance in each category? 4) Remaining unfamiliar with the goals and objectives of the rotation. Each evaluator will compare your performance to a certain standard of performance that they have in mind. How can you determine the evaluator’s standard of performance? In addition to learning about the evaluator’s expectations, ask them to describe what they consider an ideal student. 5) Not knowing who will be evaluating you. Are evaluations of your clinical performance weighted differently at your school? In other words, do attending physician evaluations carry more weight than resident evaluations? 6) Failing to realize that the team members will talk to one another about your performance. Your evaluators will often solicit opinions of your performance from other team members. The evaluator will be looking to see if team members’ thoughts are consistent with their own. If inconsistent, your evaluators may question their assessment. 7) Underestimating the importance of the write-up and oral case presentation in your evaluation. Clinicians may be too busy to evaluate your history and physical exams. Although some evaluation forms allow the evaluator to mark “not observed,” others may not. Evaluators must then draw conclusions based on other areas of work. 8) Performing poorly during an observed history and physical examination. 9) Not seeking a mid-rotation feedback meeting. 10) Remaining unaware of the factors that can cloud your evaluation. Central tendency: The evaluator rates everyone as average due to laziness or the desire to not appear too harsh or lenient. Severity bias: Harsh assessment regardless of performance (“hawk”). Horn effect: One bothersome factor leads to lower ratings across the board for a student. Recency bias: Recent poor performance affects overall rating. Primacy bias: Evaluator is not able to get past the student’s bad start. Contrast bias: Being compared against other students instead of clerkship goals. 11) Failing to realize that you may benefit from a rating error. Halo effect: Evaluator is impressed with one aspect and rates student higher overall. Leniency bias: Lenient assessment regardless of performance (“dove”). “Similar To Me” bias: Student shares something in common so is rated higher. Recency bias: Recent excellent performance makes up for previous poor performance. 12) Underestimating the likeability factor. 13) Moving to the next rotation without learning all you can from your previous experience. When you are ready for the attending to write a letter of recommendation, make it as easy as possible for him to write a glowing letter. As months pass by, specific memories of your performance might fade, making it difficult for letter writes to create a

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Hints – Clinical Rotations

James Lamberg

28Jul2010

letter with specific examples and details that back up the praise. For this reason, with every rotation, keep track of your accomplishments and the compliments you receive. 14) Failing to encourage your evaluators to turn in their evaluations. Per Hunt, over 30% of evaluation forms were turned in more than two months late. If you have impressed an attending physician, you want them to submit an evaluation. You may even expect that this will happen. Unfortunately, when clerkship directors ask evaluators to complete and submit evaluation forms, some do and some don’t. To ensure that an evaluator has submitted your evaluation form, check in periodically with your clerkship director. 15) Feeling that all is lost after a poor clinical evaluation. Successful grade appeals are the exception rather than the rule. However, if you feel that an error was made, you should certainly consider an appeal. -------------------------------------------------------------------------------------------------------------------------------------------Commonly Made Mistakes With Patients: 16) Harming the patient. You are the team’s expert on your own patients, and therefore you have the ability to prevent and catch medical errors. 17) Transmitting a nosocomial infection. The contaminated hands of clinical staff is the most frequent cause of the spread of antibiotic-resistant pathogens. 18) Introducing your self inappropriately. One option is saying “Hello, I’m student doctor Lastname,” or better is “Hello, I’m Firstname Lastname. I’m a third year medical student who is part of the team that will be taking care of you while you are here in the hospital. With your permission, I would like to ask you questions related to your medical history.” If a team member introduces you as a “doctor,” clarify your position and role to the patient at the appropriate time. Do so in a way that avoids any embarrassment to the team member. 19) Referring to your patient as a disease. 20) Forgetting to care. Strive to care for your patients as if they were your mother of father. 21) Following a script. Although you may not want to miss any details, following a scripted format impedes effective interviewing. A patient may say, “I’m so worried about what will happen to my kids if this chemotherapy doesn’t take care of my breast cancer.” As a patient, how would you feel if your physician didn’t bother to acknowledge this statement and moved on to the next question? 22) Taking it personally. Hospitalized patients often feel as if they have no control. This is a distressing feeling, one that you can diminish by keeping your patients well informed of what will happen next. 23) Using medical jargon. In your interactions with patients, remember to avoid medical jargon. Don’t use medical terms such as CHF or COPD. 24) Answering the patient’s questions without exercising caution. Take care in answering a patient’s questions. If you give the wrong answer, intentionally or unintentionally, you could create a very difficult situation. If you are even slightly less than 100% confident, then it’s best to inform the patient that you will return with the answer. 25) Putting the team at risk for a lawsuit. Per Beckman et al, communication issues play an important role in a patient’s decision to sue. Four themes are identified: perceived desertion of the patient, delivering information poorly, and either failing to understand the patient perspective or devaluing the patient of family values. 26) Spending insufficient time on patient education. Educate your patients on their illness, let them know where things stand, what’s in store for them on a particular day, and what they can expect in the long-term. 27) Underestimating the importance of including family members. Ask the patient first if they would like to be spoken to alone before the family is involved. Include family members whenever possible. -------------------------------------------------------------------------------------------------------------------------------------------Commonly Made Mistakes At The Start Of A Rotation: 28) Waiting too long to request time off. Inform all members of your team if you will be absent. Remember, you are part of a team so someone will have to take up the slack when you’re gone. 29) Letting the luck of the draw dictate who you will work with. Per University of Michigan Medical School, an attending faculty’s clinical teaching abilities have a direct positive correlation to student NBME exam performance. 30) Lacking the equipment to do the job. For all rotations, have a stethoscope and penlight. IM: reflex hammer, tuning fork, visual acuity card, ophthalmoscope. Surgery: scissors, paper tape, kerlix, cover sponges. Pediatrics: ophthalmoscope, otoscope with pneumatic attachment, calculator, reflex hammer, measuring tape, tongue blades, toy (for distracting apprehensive children). Ob/Gyn: reflex hammer, pregnancy wheel, bandage scissors, tape, gauze. Psychiatry: reflex hammer, tuning fork. 31) Lacking the necessary books. However, don’t go on a shopping spree if the school/hospital library has books. 32) Starting the rotation without talking to students who have recently completed it. Find out in advance the name of the attending physician with whom you will be working. Then check with fellow students to learn more about this attending. What is their style? How do they like to do things? What are their pet peeves? 33) Reading clerkship orientation information after the rotation starts. You want to know what is in store for you.

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Hints – Clinical Rotations

James Lamberg

28Jul2010

34) Forgetting that the clinical evaluation counts much more than the exam. Although you still have an exam at the end of the clerkship, it generally counts much less than your clinical evaluation. 35) Missing important information during the clerkship orientation. 36) Making a poor first impression. As you shake hands with team members, smile cordially, speak clearly, and address each person by name. “Dr. Lastname, I’m Firstname Lastname, a third year medical student assigned to your team. It’s a pleasure to meet you.” 37) Dressing inappropriately on the first day of rotations. Don’t dress down on the first day. Make sure to wash your lab coat do it doesn’t look dirty or stained (e.g. iodine). 38) Taking the first few days too lightly. This will help you reach the comfort zone quicker. 39) Failing to let go of the previous rotation’s culture. 40) Not understanding the culture of the new rotation. 41) Focusing on the wrong elements of the job. Your success depends not only on the quality of your work but also in the way in which you deal with people. Don’t lose sight of this important point. 42) Not meeting with the resident and intern. Some services are busy and will not set this meeting up. You should take the initiative. Ask what expectations are, responsibilities, when to arrive, and where to meet. Instead of asking when a workday ends, which may give the impression that you are lazy, ask about a typical workday. 43) Not meeting with your attending physician. Ask your attending how often you will be meeting to discuss your progress. Let your attending know that you wish to improve and are open to suggestions. 44) Meeting only your immediate team members. Try to meet as many people are you can on a typical day. Meet nurses, social workers, file clerks, radiology technicians, lab personnel, pharmacists, and the ward secretary. 45) Forgetting the hospital tour. Obtain a hospital map and keep it in your lab coat pocket. 46) Following instructions poorly. Pay attention, ask for clarification, and perform tasks sooner than later. 47) Asking few, if any, questions. Team members have worked with students in the past and know you have lots of questions. Don’t be afraid to ask. 48) Having unrealistic expectations. Don’t begin your rotation with preconceived notions. Although you may have heard that your resident or attending is hard to work with, reserve judgment. Start with an open mind. 49) Displaying a negative attitude. 50) Sticking your foot in your mouth. The hospital is a very public place and you never know who might be within earshot of your conversation. 51) Trying to make a big splash. Really use your powers of observation during the first few days of a rotation. Observe how the team members perform tasks, interact with one another, and handle themselves in situations. 52) Making the wrong mistakes. You never want your honesty, integrity, sense of responsibility, or reliability called into question. Technical and judgmental errors are expected. Professionalism errors are not. 53) Failing to build effective relationships. Go to lunch with the team or take a coffee break with them. 54) Failing to master the tasks of the job. 55) Being overwhelmed with your work responsibilities, and letting these feelings paralyze you. Do the best that you can and don’t be afraid to ask for help when you need it. You will become comfortable with your new surroundings. 56) Slacking off. It’s not enough to work hard. You must also make sure that team members see your work. 57) Believing there’s only one way to skin a cat. Team members never want to hear you say, “When I was at Hospital last month, we wrote our admission orders this way.” 58) Maintaining a stone face. You don’t need to show that you are nervous. Smile. 59) Waffling on whether to reveal your career interests. Don’t lie if you are sure about your plans, but also don’t say you are uninterested in the current rotation. 60) Staying in the observation mode. Ask the resident to assign you a patient. Start the rotation with no more than one or two patients at a time. Assume primary responsibility and strive to perform all patient care-related tasks. 61) Remaining unfamiliar with the chart. You want to know what happened to your patient while you were gone. -------------------------------------------------------------------------------------------------------------------------------------------Commonly Made Mistakes On Call: 62) Starting day one of the clerkship without knowing if you are on call. Some students are put on call for the first day of rotations. If you happen to be one of them, you need to know this before you start. 63) Remaining unfamiliar with your responsibilities. Ask your resident and intern who will be on call with you. 64) Being inadequately prepared for your call. Bring a change of closes, personal hygiene items, snacks, medical equipment, books/resources, and maybe some cash for the vending machine since the cafeteria will likely be closed. 65) Not being visible or easily accessible. The resident may say they will page you and you can retreat into the call room. The problem is that every moment is precious so the resident may just complete a task instead of paging you and waiting for a response. A better approach is to be present. Consider shadowing your resident if they allow it. If

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Hints – Clinical Rotations

James Lamberg

28Jul2010

shadowing is discouraged, plant yourself where the intern and resident can’t help but notice you as they scurry to around to completing their work. Be around but not in the way. 66) Picking up a patient later rather than sooner. What residents consider “boring” may have a great teaching value for students. Don’t wait around for the “exciting case” that may never come. 67) Working up an insufficient number of patients. 68) Evaluating the patient superficially. Even though you may not be evaluated during a patient physical exam, your attending can assess your work during the oral case presentation the next day. 69) Obtaining an incorrect medication history. Ask yourself what medications is the patient actually taking, if they are following the prescribed schedule, if not then why not, what over-the-counter medications they are taking, if they are taking any nutritional supplements, and if they are taking any herbal or natural medications. 70) Not evaluating the patient on your own. Your job it to perform a complete history and physical examination, while the intern and resident perform a focused exam. If you see the patient together, you may need to come back and fill in the gaps. 71) Spending too much time reading and not enough time with the patient. 72) Functioning as the patient’s medical student. Strive to function as the patient’s intern. Get a history, perform the physical exam, gather laboratory results, gather diagnostic studies, determine the cause of the patient’s symptoms, decide on further diagnostic tests, develop a treatment plan, write the admission orders, record the history and physical exam in the patient’s record, prepare an oral case presentation to deliver the next day (post-call day), periodically check-in with the patient, answering patient’s and family’s questions. 73) Letting others write the admission orders. 74) Writing incorrect medication orders. Ask yourself if you consulted a prescribing reference, if the patient is allergic to the medication, if the medication is contraindicated, if the medication is teratogenic, if there may be drugdrug interactions, if the dose needs to be adjusted for renal dysfunction, if the medication is spelled correctly, if abbreviations have been avoided, the route of administration, if the dosage was given a date/time, if your name was printed along with your beeper number, and if your handwriting is legible. 75) Going into attending rounds without having first met with the intern or resident. 76) Leaving for the day without offering to help the team. Don’t leave without offering to help other team members. 77) Arriving for rounds with the post-call look. Clean yourself up before rounds start the next morning. -------------------------------------------------------------------------------------------------------------------------------------------Commonly Made Mistakes When Presenting Newly Admitted Patients: 78) Underestimating the importance of the oral case presentation. No matter how well you understand your patient’s illness, if you can’t clearly and confidently convey your thoughts during the oral case presentation, you will not be seen as competent or effective. 79) Being unaware of the qualities of an outstanding oral case presentation. Your presentation should be well organized, clear, concise, provide relevant information, and have an excellent assessment and plan. 80) Presenting the case without realizing what the attending is seeking. 81) Presenting the case without knowing how much time you have. Typically 5-15 minutes. 82) Presenting for longer than the allotted time. Time yourself while rehearsing the oral presentation. 83) Presenting a case with too little or too much detail. 84) Presenting a verbatim reading of the patient’s write-up. 85) Not practicing your oral case presentation. Videotaping yourself may be an effective way to improve. 86) Speaking softly. 87) Speaking too quickly or too slowly. To avoid delivering a boring presentation, vary your rate of speech. Slow down if you want to emphasize certain points. A short pause is particularly effective in this regard. 88) Speaking in a monotone. Many students way do not realize it until they listen to a recording of themselves. 89) Mispronouncing words. There are online resources with audio pronunciations of drug names. 90) Speaking with annoying speech habits. Avoid phrases such as, “um,” “uhh,” “like,” and “you know.” 91) Minimizing the importance of body language. Maintain eye contact with team members. Display good posture. Never invade a colleague’s space. Avoid distracting behaviors such as playing with your hair. 92) Letting the awkwardness and discomfort of the first few oral case presentations get to you. 93) Paying poor attention to other student presentations. 94) Letting your anxiety take over. While practicing, visualize the room, the audience, and yourself during the presentation. Picture yourself impressing the team. This can help “speech-anxious subjects” (Hu). 95) Following an improper format or order. Steps are patient identification, chief complaint, history of present illness (HPI), past medical/surgical history, medications, allergies, social history, family history, review of systems (ROS), physical examination, lab/imaging/diagnostic studies, summary, and assessment/plan. Don’t stop your

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Hints – Clinical Rotations

James Lamberg

28Jul2010

presentation before the assessment/plan if you fear being wrong, as committing to a diagnosis with supporting information will be looked upon favorably by your attending. 96) Transitioning without the use of headings. Say, “Oh physical exam…” instead of diving in. 97) Presenting irrelevant information. Include only information that helps the listener care for the patient. 98) Letting interruptions fluster you. Assume you will be interrupted. Don’t get annoyed by interruptions as this might signal that the attending is paying close attention to your presentation. 99) Not obtaining feedback. Obtain feedback soon after you present. 100) Letting one mistake throw off your presentation. 101) Not projecting confidence. Body language and voice quality is very important. 102) Lying. If an attending asks you about a patient’s dorsalis pedis pulse and you did not check them, do not say they were normal. It is not possible to provide the best patient care if team members are not honest. 103) Ignoring audience response. -------------------------------------------------------------------------------------------------------------------------------------------Commonly Made Mistakes On Write-Ups: 104) Underestimating the importance of the write-up. Student write-ups are generally the most detailed document in the chart. They are likely to be referenced by other healthcare professionals, not only during the patient’s present admission but for many years to come. 105) Not ascertaining the expectations of the attending physician. The quality of your write-ups will significantly contribute to the attending’s impression of your clinical performance. 106) Late submission of the write-up. Many students commit this mistake due to time pressures. The most common reason is perfectionism; at some point, you have to let it go and submit it else your evaluations will suffer. 107) Submitting an incomplete write-up. This is the most common error (McLeod). One study showed that residents recorded only a little over half of all medical history information during clinical interviews (Moran). 108) Submitting an illegible write-up. Recognize poor penmanship so you don’t compromise patient safety. 109) Submitting your write-up without comparing it to previous ones. 110) Not doing a tremendous job on the first write-up. Hold your write-up out in front of you and ask if it looks good. Are their coffee stains? Are their clear breaks 111) Submitting a write-up with poor grammar and incorrect spelling. 112) Submitting a write-up with improper abbreviations. There are online resources for improper medical abbreviations. It is a good idea to print one for your lab coat pocket. 113) Submitting an inaccurate write-up. Once the write-up is in the patient’s medical record, it cannot be changed. One study found the incorrect inclusion or omission of a patient medication occur 83% of the time (Beers). Another found no documentation of previous heart failure in 58% of patients hospitalized for myocardial infarction (Cox). 114) Submitting a disorganized write-up. 115) History of present illness errors. Poor characterization of patient signs and symptoms was the third most frequent problem found in student write-ups (McLeod). 116) Problem list errors. Include a problem list, which is a compilation of the patient’s active medical problems. Include all symptoms, known illnesses, abnormal physical exam findings, abnormal test results (ECG, laboratory, imaging, etc.) but exclude inactive problems (e.g tonsillectomy when the now adult patient was a child). 117) Submitting a write-up that lacks appropriate assessment and plan. Explain your thoughts; how you came to a particular diagnosis, why other conditions in the differential are less likely, and the rationale for the diagnostic and therapeutic plan you are recommending. The University of Minnesota Medical School found formulation of a reasoned differential diagnosis and plan was the most discriminating factor when differentiating between average and superior medical clerks (Parenti). Clerkship evaluations forms often ask evaluators to comment on a student’s use of the literature. Because many students don’t realize this, they fail to show their team that they are reviewing literature. For example, incorporate a recent clinical trial into the assessment and plan. 118) Passing off the work of others as your own. Do not copy an intern or resident’s assessment and plan without giving them credit. Devise the assessment and plan on your own. 119) Submitting the first write-up without having it reviewed by the resident. 120) Not seeking feedback on the quality of your write-ups. -------------------------------------------------------------------------------------------------------------------------------------------Commonly Made Mistakes When Giving Talks: 121) Not volunteering for a talk. Volunteer with enthusiasm, even if it’s the last thing you want to do. 122) Choosing the wrong topic. Choose a topic you know something about, one that you have an interest in, and one that will be of interest to your audience.

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James Lamberg

28Jul2010

123) Preparing for a talk without knowing when you are expected to deliver it. Don’t accept vague deadlines from physicians; it is crucial to know when you will be giving a presentation. Start right away. 124) Being unaware of your allotted time. If the attending physician doesn’t tell you how much time you have to speak, you should ask. 125) Procrastinating. Start preparing right away. The more you prepare, the more confident you will be. 126) Preparing a talk without knowing your audience. How many people will be in the audience? How familiar is the audience with the subject? Is this information relevant? What questions might they ask? 127) Preparing a talk without knowing the purpose of the talk. Thing along the lines of “I want my listeners to know how to manage an acute gout attack.” 128) Failing to captivate the audience from the get-go. Ask a rhetorical question, “Did you know that the diagnosis of pulmonary embolism is missed in about 400,000 patients per year?” Make a bold statement or share a starling statistic. Make a historical reference. Providing a thought-provoking quote. Tell a brief story. 129) Utilizing inappropriate resources. Always use authoritative texts and resources. Never use Internet searches. 130) Overloading your audience with information. If a point does not support your talk’s purpose, cut it out. 131) Presenting inaccurate date. Make sure your statistics and information is up-to-date. 132) Practicing incorrectly. If time is an issue, cut out material instead of trying to increase your pace. It is also a good idea to have a paper copy of your talk, as you never know when a projector bulb till burn out or if other technical difficulties may arise. 133) Reading your talk word for word. This is boring for all who listen. Design your viewable presentation in an outline format and then fill in the “story” as you talk. 134) Speaking in a monotone. Vary your inflection. 135) Speaking without gestures. Don’t bite your nails, keep your hands in your pocket, or grip onto the microphone. Other bad gestures include playing with keys, rocking back and forth, rubbing the back of your neck, playing with your hair clenching your fists constantly, pacing back and forth, and fidgeting with clothing or jewelry. 136) Using fillers. Record your talk, as you may not realize that you use fillers such as “um” or “uh.” 137) Speaking too quickly. Too many ideas presented too quickly will not be understood. 138) Letting your anxiety take control. Surveys show public speaking is the number one fear, ranked ahead of the fear of death. It’s natural to be nervous, but you need not express this to your audience. 139) Concluding your talk with a whimper. Use a strong conclusion to leave your audience with a favorable impression. Examples are: “In concluding, I want to…” and “To wrap up my talk…” 140) Avoiding eye contact. “Eye contact is the most critical component of effective delivery” (Spinler). 141) Showing little, if any, enthusiasm. “There are no dull subjects, only dull presentations.” Fake it if you must. 142) Giving a talk without using visual aids. Tips for creating a slideshow: don’t read the text, don’t use font colors that contrast with the background, don’t change background (medium blue is popular), maintain consistency, don’t use full sentences (<6-7 words), less is more, use 18-font size or larger, don’t use fancy founds (pick standard like Arial or Times), don’t capitalize entire words, proofread, and avoid complex tables/charts/graphs/diagrams. 143) Allowing audience interruptions if you can’t handle them well. Ask for questions to be held to the end. 144) Being afraid to say, “I don’t know”. Let your listeners know when you will answer questions, repeat the questions (especially in a large group), don’t bluff or lie or apologize if you don’t know, consider deferring the question to an expert if they are in the room, and get back to the questioner with the answer at a later time. 145) Not soliciting feedback. -------------------------------------------------------------------------------------------------------------------------------------------Commonly Made Mistakes In The Outpatient Setting: 146) Underestimating the utility of outpatient rotations as preparation for the Step 2 CS or Level 2 PE exam. Many students are rarely or never observed doing patient history and physical exams. 147) Forgoing an orientation. Meet with nurses, assistants, and receptionists; they are your team. 148) Lacking an understanding of your responsibilities. 149) Walking into the exam room with no information about the patient or reason for the visit. Know what the chief complaint is, active issues, medications, and diagnostic test results. If you are having trouble finding the information, have a preceptor orient you to the key parts of the chart. 150) Introducing yourself to the patient improperly. Well-intentioned preceptors may introduce you as a “young physician” or “physician-in-training,” it is important that the patient understands you are not a doctor but a medical student. They have the right to refuse a history and physical exam; don’t take it personally. 151) Focusing on the wrong patient issues. In a videotaped analysis of histories performed by senior medical students, 24% of all students did not ascertain the patient’s main problems (Rutter). 152) Overlooking key aspects of preventive care.

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Hints – Clinical Rotations

James Lamberg

28Jul2010

153) Documenting poorly. 154) Not performing a thorough analysis of the data. What is the differential, what is the most likely diagnosis, what tests are needed, what is the treatment plan? 155) Wasting your downtime. Refrain from unprofessional behavior or casual conversation when in public areas. 156) Underutilizing electronic resources. Use resources like UpToDate, Medscape, PubMed. 157) Taking too much time to present the case. Be concise, especially in the outpatient setting. 158) Presenting in an informal manner. 159) Being unprepared for your preceptor’s questions. Questions will either be clarifying (“What’s the dose of the patient’s lisinopril?”) or probing (“What do you think is going on with this patient?”) 160) Presenting the patient without formulating an assessment and plan. Commit to a diagnosis, even if you feel you are going out on a limb. Explain how you justify that conclusion based on the presentation. 161) Failing to follow up on patient issues. This includes arranging for lab work or diagnostic tests, scheduling follow-up appointments, dictating clinical notes, educating the patient, and searching literature to answer a question related to the evaluation or management of the patient’s problem. 162) Preparing inadequately for attending rounds. Your goals are to learn as much as possible and to impress the attending physician. 163) Starting off on the wrong foot with the attending physician. Show proper respect, do your job, do your homework, show that you are a team player, display a strong work ethic, and ask for help when you need it. 164) Being a difficult student. Three problems have been identified (Blue). Non-participating, quiet, passive students. Disruptive students who are sarcastic, disrespectful, or interrupts discussion. Student who tries to take over the group and control it. Even one instance of bad behavior can taint your entire performance. For example, it may be impossible to recover from a disrespectful comment, racist remark, or deceptive act. 165) Participating infrequently during rounds. One study showed students participated only 4% of the time (Foley). Tips to increase participation include: do your homework, sit where you will be noticed, establish good relationships with team members, maintain eye contact, operate with the philosophy that there are no stupid questions, and speak your thoughts. 166) Erring at the bedside. Several studies show that patients generally enjoy bedside visits from the team. Tips include closing the patient’s door or privacy curtain when entering the room, asking permission to turn off the radio/TV, not answering a page with the patient’s room phone, do not carry on side conversations, do not laugh at a patient unless you are absolutely sure it was a joke, do not eat or drink in the room, and do not lean on the wall. Other tips include being sensitive to the patient, avoiding words like “denies” or “admits” (e.g. “patient admits to drinking 5 beers a day”), and avoiding detailed discussion of differential diagnosis as well as the word “cancer” unless you were given permission by the attending. 167) Losing track of your accomplishments during a rotation. Keep track of positive accomplishments, such as patient thank-you notes or comments after a particular presentation. 168) Allowing shyness to affect your evaluation. Extraversion correlates positively with clinical evaluations. 169) Underestimating the importance of being on time. Don’t be late, not even once. 170) Offering no reason for your tardiness. Do not assume that a team member has informed the attending to make sure you are on the same page. Exceptions to tardiness include a patient problem that prevents you from being on time, an important task (e.g. resident sent you to get radiographs 5mins before rounds), and conferences/lectures. 171) Leaving rounds early. If you must leave rounds because of a conference, be sure to return immediately after the conference ends in case rounds are still in progress. 172) Being seen and not heard during rounds. A good teacher will always respond favorably to questions. They also expect questions. If you are hesitant to ask questions, consider developing a list before rounds start. 173) Asking questions without permission. Do not ask questions when a patient’s condition has taken a sudden turn for the worse or during a delicate moment in the operating room. Seeking permission is not always necessary, but when the clinician is busy it provides a simple courtesy that demonstrates respect. 174) Listening passively. Jot down major points if necessary. 175) Underestimating the importance of displaying enthusiasm. Displaying enthusiasm regularly can have a “halo effect” on your work. People will tend to view all aspects of your work in a more positive light. 176) Waiting for a spark. This can get you labeled as unenthusiastic. 177) Dispensing with the greeting. When in the team room, make sure you know everyone in the room. 178) Dreading pimp questions. Embrace these teaching opportunities. 179) Allowing the audience to prevent you from performing up to your capabilities. Remember when one team member performs well, it reflects well on the entire group.

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Hints – Clinical Rotations

James Lamberg

28Jul2010

180) Inappropriately preparing for attending rounds. You will likely receive clarifying questions (“How did the patient describe her pain?”) or probing questions (“What exam findings would you expect with aortic stenosis?”). 181) Answering questions with hesitation. Don’t diminish the strength of your responses with the words, “I think” or “I’m not sure but…” or “I may be wrong but…” 182) Answering questions incorrectly. Small handbooks lack the depth and breadth of information required to take care of patients on a day-to-day basis. Field textbooks may fail to provide information as well, which is why using up-to-date online information (e.g. Medline, UpToDate) is important. If another student is unable to answer a question, refrain from jumping in, no matter how tempting it may be. Wait until you are asked the question or it is thrown out to the entire group. Never make a colleague look bad. 183) Having diarrhea of the mouth. Don’t ramble on in hopes that you hit the correct answer. 184) Sitting too far away from the attending physician. 185) Not modeling yourself after a “with it” team member. You will come across team members that are highly regarded. What is it that makes these people stars? Listen to what others say about them, observe how they work and interact with colleagues, and pattern yourself after them. 186) Lacking appreciation. However, excessive praise may arouse suspicion of a hidden agenda. 187) Reading only about your own patients. 188) Preparing inadequately for an attending physician’s talk. 189) Using humor inappropriately. It is never acceptable to make fun of your patients. Even if other team members are making jokes at a patient’s expense, do not join them. You never know when a patient or family member may be within earshot of your conversation. It may also diminish your standing with team members. 190) Accepting praise poorly. “Thank you” is all that is needed. 191) Being unable to recover from a poor performance. No matter how well you prepare, there will be times when things don’t go as well as you had hoped. Just do your best and get ready for the next challenge. 192) Letting your dislike of the rotation affect your relationship with the attending physician. 193) Letting your dislike of the attending physician affect your rotation performance or working relationship. 194) Dealing poorly with a rude attending physician. One option is to say, “You seem to be really busy. I’m sorry I interrupted you. I’ll speak with you at a better time.” 195) Destroying your credibility. Don’t lie. Once you are found out, it will be difficult, if not impossible, to restore the trust you have lost. Everyone will always wonder, “What else are you lying about?” 196) Doing only what’s expected. The benefits might not occur immediately, but will eventually. 197) Succumbing to the pressure. Avoid saying, “I’m sorry, I’m just nervous” or displaying mannerisms that show you’re anxiety. Let others draw their own conclusions. 198) Listening poorly. During rounds, don’t look at your watch constantly, look through papers (unless pertinent), slouch in your seat, or talk to others. You would be surprised how often students fall asleep during attending rounds. Don’t think it won’t happen to you. The combination of fatigue, long hours, lack of sleep, and boredom can easily cause you to nod off. To prevent it from happening, take notes during rounds. 199) Being unable to read people. Three types of problematic behaviors have been identified (Burack). These are showing disrespect for patients, cutting corners, and outright hostility or rudeness. However, it was noted that attending physicians often did not respond to these behaviors, and when they did it was via nonverbal gestures such as rigid posture, failing to smile, or remaining silent. 200) Compromising your integrity. One study (Anderson) showed 21% of students reported a pelvic exam as ‘normal’ and 35% reported a lab test or x-ray as ‘normal’ when they hadn’t been completed. 201) Not taking initiative. Look for opportunities to demonstrate initiative. Don’t wait for other team members to invite you to observe a procedure or perform one. If a procedure is to be performed, ask if you can do it. If not, ask if you can observe. Better yet, ask if you can help get everything ready for the procedure. 202) Reacting rather than anticipating. Anticipate different outcomes. For example, if a patient with suspected pyelonephritis does not get better the day after antibiotics are started, you should not be lost. 203) Showing no diplomacy. If your attending asks how the rotation is going, be very positive, unless of course you have a major concern. Answer with, “Great,” “I’m really enjoying it,” or “I really appreciate all the teaching.” 204) Talking too much. Overly talkative students tend to dominate rounds; the attending should be doing this. 205) Not showing compassion. The needs of the patient should remain first. 206) Putting your foot in your mouth. Saying, “Well I really don’t like medicine. I’m going into ophthalmology.” will likely not go over well. 207) Lacking confidence. If you appear and act more confident than you feel, those you work with will have more confidence in you.

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Hints – Clinical Rotations

James Lamberg

28Jul2010

208) Making the resident or intern look bad in front of the attending physician. Try to answer questions with humility, such as “I was just reading about this yesterday and I found out that…” 209) Functioning at the lowest student level. The RIME method is used to describe the four stages of student development; Reporter, Interpreter, Manager, Educator. Even when unsure, outstanding students will offer a plan. Team members are impressed with students who have given a problem considerable thought and are brave enough to recommend a course of action. 210) Not knowing how to interpret an ECG or chest film. For ECG, look at rate, rhythm, intervals, blocks, axis, hypertrophy, conduction disturbances, MI, ST-segment changes, T-wave changes, Q waves, and changes from previous. For chest film, look at patient name, date of study, PA or AP film, rotation of the patient, penetration of the film, bones, breasts, soft tissue, costophrenic angle, lung markings/fields, mediastinum, cardiac shadow, cardiac chambers, and comparison with previous chest film. If you don’t know how to interpret an ECG or chest x-ray, have your resident introduce you to their system of analysis. Do this early (before your attending asks you). 211) Differential diagnosis of an abnormal lab test is not known. Check results before attending rounds. 212) Letting unanswered questions in rounds remain unanswered. Take the initiative to look up answers, and even share the results with the team at the appropriate time, along with a copy of a relevant article. 213) Letting favoritism affect your performance. 214) Relying too heavily on self-assessment. Get feedback from others. 215) Not asking for feedback. Get frequent feedback. 216) Settling for nonspecific feedback. 217) Receiving feedback poorly. Pay attention to negative comments; sometimes they get sandwiched between positive comments. Summarize your feedback to ensure understanding. 218) Not acting on feedback. It’s never too lake to make changes. 219) Completing the rotation without a final meeting with the attending physician. -------------------------------------------------------------------------------------------------------------------------------------------Commonly Made Mistakes With Residents And Interns: 220) Not being a team player. Negative behavior (per Lavine) was described as students thought to be shirking responsibility or “acting for the sake of appearance.” 221) Being disorganized. Decide on a system that works for you, such as a clipboard, blank or pre-made note cards, pocket-sized notebooks, or a personal digital assistant. Key information to have at your fingertips includes: patient name, medical record number, room number, date of birth, admission date, chief complaint, HPI, medications, daily vital signs and inputs/outputs, physical exam findings, lab results, and a problem list. 222) Taking care of patients without a to-do list. Keep your to-do list in one location and not written on your hand. 223) Taking care of patients without prioritizing the tasks that need to be completed. Do as much work as you can in the morning. If something is particularly important, speak with the appropriate person to make sure it gets done. 224) Assuming that others believe you are working hard. Seek input on your work ethic from residents. 225) Thinking that certain work is beneath you. Don’t argue with “scut work” (menial tasks). Even mundane tasks have learning value. 226) Making the intern and resident look bad. If you learn of a new patient development just before attending rounds, you may not have a chance to inform the intern or resident. If this happens, you will have to present the information delicately so that you do not inadvertently show up your intern or resident. 227) Not updating your intern and resident. 228) Being inaccessible. Keep your intern and resident informed. 229) Missing deadlines. The best students don’t surprise their interns; if a deadline can’t be met, they inform their intern well in advance. This allows the intern to step in and help complete the task. 230) Dropping the ball. Don’t cross items off your to-do list until they are truly completed. 231) Not maximizing teaching from your resident and intern. Determine what your residents’ interests and strengths are, be visible and accessible, and express your appreciation for their teaching. 232) Handling conflict poorly. You should not be harassed, discriminated against, or belittled. Unfortunately, the literature shows that such behaviors do occur. Should it happen, consider discussing it with the clerkship director. 233) Mishandling the toxic colleague. Consider stressors (illness, family issues) that may be causing this colleague to act in a negative way. Never make a classmate look bad in an effort to make yourself look better. 234) Complaining. Complaining about work generally doesn’t help. Vent outside of work. 235) Dating team members. Keep personal life separate from work. A relationship between a supervisor and a trainee is highly discouraged. 236) Letting your guard down. Be friends with your resident and intern after rotation. Until then, treat them as you would any other person who has considerable influence over your grade and career (because right now, they do).

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Hints – Clinical Rotations

James Lamberg

28Jul2010

237) Not paying attention during work rounds. 238) Knowing a lot about your patient. You need to know everything about your patient. 239) Letting your intern write orders on your patients. Unless forbidden by the clerkship, write all your orders. 240) Being arrogant. A confident student believes in them self, while an arrogant student considers themselves superior. Confident students are not afraid to admit mistakes, while arrogant students never own up. 241) Not eliciting feedback from the resident and intern. One study showed residents offered feedback to team members in only 11% of patient encounters (Wilkerson). 242) Leaving the rotation without having a final feedback meeting with your intern and resident. -------------------------------------------------------------------------------------------------------------------------------------------Commonly Made Mistakes With The Written Exam: 243) Underestimating the importance of the written exam. 244) Preparing for the exam without knowledge of the exam format. 245) Delaying examination preparation. For each disease, ask what the symptoms are, what the signs are, what the differential diagnosis is, how to decide between diagnoses, how to work-up the disease, what tests are available to confirm the diagnosis, what treatment options exist, what the prognosis is, and the pathogenesis. 246) Preparing for the exam without setting up a schedule. 247) Preparing for the exam without taking the time to review the content of the exam. Many studies show student performance on NBME subject exams improves with clerkship experience (Manley) (Reteguiz) (Hampton) (Cho). 248) Taking the exam without pacing yourself. You get a little over a minute per question. 249) Reading the clinical vignette first. Read the question first, then the vignette. 250) Reacting emotionally to questions. Made an educated guess and move on. There is no penalty for guessing. -------------------------------------------------------------------------------------------------------------------------------------------Guide For Wards Success – First Aid For The Wards (Le, Bhushan, & Amin) -------------------------------------------------------------------------------------------------------------------------------------------Some common mistakes that students make when coming to the wards include: * Not understanding the responsibilities and expectations associated with the rotation * Not seeking timely feedback * Not using appropriate pocket references and clinical texts * Not knowing what to study on the wards * Failing to be a team player * Inefficient organization and execution of daily work * Insufficient preparation for oral presentations for attending rounds * Failing to streamline personal and family responsibilities * Scheduling key rotations too early or too late. You should understand how your team works and how you fit in. In this regard, your goal should be threefold: to function as a productive team member; to care for your patients; and, of course, to learn. Winning friends and allies on the team can help ensure that you receive the best teaching and support possible and that you always get the benefit of the doubt. For example, if you help the intern with daily patient care, also known as “scut work,” he or she may prep you for the inevitable “pimp” questions that the attending or resident may ask. By contrast, making the intern or resident look bad in front of the attending will compromise your team’s trust in you. Attending: As the head of the team, the attending is usually involved in the most critical treatment decisions affecting your patients, such as whether a patient needs chemotherapy as opposed to radiotherapy for a tumor. The logistics of patient care (e.g., scheduling, fine-tuning of treatment) are typically left to the resident and intern. Resident: The resident (PGY-2 and up) is a house officer who has gone through internship. He or she works closely with the attending to devise and manage the treatment plan for your patients. The resident is also responsible for teaching you and the intern via didactics or informal pimping. Intern: The intern (PGY-1) gets the practical aspects of wards work done for the team and is responsible for executing the treatment plan under the direct supervision of the resident. Any patient care that does not get done by other team members falls in the lap of the hapless intern. Intern rules: eat when you can, sleep when you can, leave when you can. Interns can be your best friends; keep them informed. Subintern: The subintern is a 4th year student who has the same responsibilities as the intern. Although subinterns have no responsibility for evaluating or teaching you and usually do not cover your patients, they can often serve as a valuable source of clinical pearls and practical information about the wards and applying for residency. Nurses can make or break your rotation. Never leave a mess for a nurse to clean up.

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Hints – Clinical Rotations

James Lamberg

28Jul2010

If nurses like you, they may feed you extra information on your patient, clue you in on important treatment issues, and take the time to teach you important scut skills, such as placing Foley catheters or inserting IV lines. Be friendly yet assertive when asking for help. -------------------------------------------------------------------------------------------------------------------------------------------Pre-Rounds Checklist: * Review the events that have taken place since last night by checking the charts for new notes, talking to the crosscovering intern, and touching base with the nurse. * Subjective status: Ask the patient how he or she feels. * Objective status: Obtain vital signs and conduct a brief physical exam focused on findings that are relevant to current problems. * Check new labs, culture results, study results, and radiographs. * Formulate a plan for the patient for today (break it down by problem). A good sign-out is the mark of a good student. The operating room is often a place for rampant pimping, so bone up on your reading the night before the case. Quick framework for a differential diagnosis: MINT CANDY. Metabolic, Infectious, Neoplastic, Trauma, Collagen vascular disease, Allergies, ‘N’ything else, Drugs, Youth (congenital). Focus on past discharge summaries and medical student admission notes. Remember to begin your interview with open-ended questions (e.g., “What brought you to the hospital?”), a tactic that will give the patient some degree of control over the interview process. Two reasons not to do a rectal exam: you don’t have a finger or the patient doesn’t have a rectum. Classically, the formal oral presentation is given in seven minutes or less. Presentation: Identification, chief complaint, HPI, PMHx, All/Meds, SHx, FHx, ROS, PE, tests, assess, plan. Standard orders for notifying house officer: NOTIFY HOUSE OFFICER: T > 38.4°C, pulse > 120 or < 50, SBP < 90 or > 180, RR<8or>30,O2 sat<90%. -------------------------------------------------------------------------------------------------------------------------------------------Common PRN medications: * Acetaminophen (Tylenol) 650 mg PO q 4 h PRN temp > 101.5°F * Bisacodyl (Dulcolax) 10 mg PO/PR QD PRN constipation * Diphenhydramine (Benadryl) 25 mg PO QHS PRN insomnia * Maalox 10–20 mL PO q 1–2 h PRN dyspepsia * Lorazepam (Ativan) 1–2 mg IM/IV q 6 h PRN anxiety/agitation * Promethazine (Phenergan) 25 mg PO/IM q 4 h PRN nausea or ondansetron (Zofran) 4mg IV q 4 h PRN nausea -------------------------------------------------------------------------------------------------------------------------------------------Tips for procedures: * Before performing any significant procedure, obtain informed consent from the patient. To do so, you must explain the procedure, its indications, its risks and benefits, any alternative options, and the risks and benefits of not having the procedure. Be sure to document the patient’s consent or place a signed consent form in the chart. Some hospitals allow students to consent patients for simple procedures and operations; others do not. * Have everything you need ready at the bedside (think through what you will require in advance). * Gather enough materials for multiple tries (expect to miss the first IV or venipuncture). * Position the patient and yourself for comfort (e.g., raise the bed so that you don’t have to bend over). * Always remember universal precautions. * Prepare for a potential mess by having gauze and disposable drop cloths positioned as necessary. * Do not be discouraged if you are not successful. Learning how to do a procedure takes practice. * Clean up after yourself. Discard all of your sharps in the proper receptacle. * Write a procedure note for any invasive procedure you perform, including: LP, thoracentesis, paracentesis, and central line placement, and be sure to place it in the chart. * Basic procedures for a junior student: ABGs, blood culture, ECG, IV placement, NG tube placement, surgical knots, suturing, urine (Foley) catheterization, venipuncture, wound dressing changes. * Advanced procedures for a junior student: arthrocentesis, chest tube insertion, central line placement, LP, obstetrical delivery, paracentesis, thoracocentesis. -------------------------------------------------------------------------------------------------------------------------------------------Tips for being a great communicator: * Respect the privacy and wishes of the patient. Never discuss patients in the elevator, cafeteria, or public places. * Be as honest and direct as possible. Update family members regarding the progress of their loved ones. If it were your grandmother in the hospital, you would want the doctor to keep you informed.

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Hints – Clinical Rotations

James Lamberg

28Jul2010

* Immediately inform the patient of any upcoming studies and events. At the beginning, make sure you have a resident or an attending at your side when you break bad news to a patient or his or her family. Residents and attendings have more experience in helping patients and families deal with the emotional repercussions of an illness, and they can also help you deal with any possible backlash. * Choose a quiet time to talk (i.e., when nursing staff are not around) as well as a private location in which to do so. * Keep technical jargon to an absolute minimum, and explain any medical terminology you use. * Always finish by asking, “Do you have any questions?” * Never fudge an answer. If you are unsure what to say, tell the family that you will consult with your team and get back to them promptly. * Beware of becoming less understanding and empathic toward patients as the year progresses. Always have a clear question to ask a consultant. Pocketbooks and handbooks. When you have five minutes before attending rounds, you can quickly read a pocket resource to get the “big picture” about a disease. One example is the Washington Manual of Medical Therapeutics. Sometimes students on the wards may find themselves serving as a mobile supply cart for the attending and house staff. This may sound demeaning, but simple things such as having extra gloves, 3x5 index cards, tongue blades, or pens will save time on rounds and make your team members’ lives a little easier. So keep your pockets well stocked. Attendings will often borrow your stethoscope, pen, or penlight. Make sure you get your pen back if borrowed (attendings are especially notorious for disappearing with them), or bring extras every day. Commit all tasks to a to-do list. Write down each task immediately. Remember that you will be bombarded with multiple responsibilities while on the wards, so it is inevitable that you will forget something. You should thus try to add even the “smallest” tasks to your to-do list. Surviving Call Nights: A travel alarm (or the alarm on your pager, if it is equipped with one) is essential for surviving call nights. Do not rely on the hospital operator to wake you up. Nor should you rely on your intern to wake you up, as he or she may be too busy to remember to do so. Make an “on-call” bag with a toothbrush, a hairbrush, a razor, and a change of clothes if you are working in a clinic the next day. Sleep whenever possible; eat whenever possible. Bring a reference to learn about your patients’ problems when you find you have downtime. Third-year evaluations are crucial to a successful residency application. Find out what your team expects of you on the very first day of the rotation. Treat all body fluids as if they are potentially infectious. Never recap, bend, or break a sharp. Always report a needlestick (e.g. Needlestick Hotline). If stuck, go immediately to the Emergency Department. Patient Death: Despite the best efforts you and your team might make, some of your patients will die under your care. The first patient death can be particularly disturbing, especially if you developed any personal attachments to the patient. You should thus consider discussing the patient’s death with your team or with other students if they are receptive. Good social and family support is also of benefit. Seek confidential counseling if necessary. As you continue your clinical training, you will learn to deal more effectively with patient death. However, do not distance yourself so much from the patient that you lose the human perspective. Do whatever it takes to stay awake. Personal safety is a priority with potentially violent patients. Do not do your most likely specialty first. During the first few weeks of your clerkships, you won’t even know where the bathroom is, let alone competently function as a health care provider. It is therefore important to give yourself a chance to get the general feel of the hospital wards, to understand the role you will play, and to become comfortable presenting patients and writing notes. With this in mind, your first rotation should be in a field that you are not likely to enter. -------------------------------------------------------------------------------------------------------------------------------------------One week before; You will feel less lost on the first day if you follow these general rotation-specific guidelines: * If you’re starting neuro, practice the neuro exam. * If you’re starting psych, practice or review the psych interview. * If you’re starting medicine, review normal values and the H&P. * If you’re starting surgery, review knots, sutures, and what goes in a preop, brief-op, postop, and progress note. -------------------------------------------------------------------------------------------------------------------------------------------Shorthand For Laboratory Values (See Maxwell’s Quick Medical Reference): pH/PCO2/PO2/HCO3 Ca Na Cl BUN Hgb PT PTT Glucose Mg PO4 WBC Platelets K HCO3 Cr Hct INR --------------------------------------------------------------------------------------------------------------------------------------------

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Hints – Clinical Rotations

James Lamberg

28Jul2010

Progress Note (SOAP + Labs & Studies): Service (e.g. General Medicine, General Surgery), Hospital day #__ Postop day #__ Antibiotic day #__ S: patient comments or complaints, nursing comments O: Vitals: blood pressure, pulse, respirations, temp, weight, O2 sat Ins/Outs: IV fluid, PO intake, emesis, urine stools, drains Exam, Meds: physical findings, pertinent routine or new medications Labs: new laboratory or procedure results A: assessment based on above date P: medication changes, lab tests, procedures, consults, discharge -------------------------------------------------------------------------------------------------------------------------------------------Interview Mnemonic for Patient History (CODIERS SMASH FM, TACOSSS): C: Chronology. Have you ever had this before? How has it changed? What was the order or symptoms? O: Onset. When did current symptoms start? D: Description/Duration: What does it feel like? How long does it last? I: Intensity. On a scale from 1 to 10, ten being the worst pain you’ve ever had, how is this? E: Exacerbating factors. What makes it worse? R: Remitting factors. What makes it better? S: Symptoms associated. Review of Symptoms (ROS) questions. S: Social Hx (TACOSSS). Tobacco, alcohol, caffeine, occupation, street drugs, supplements, sexual history. M: Medications: Name, dose, frequency, compliance. A: Allergies. Food, environmental, drug, and what happens with each. S: Surgical history: What? When? H: Hospitalizations: What? Where? When? F: Family history: Parents, siblings, children. M: Medical history: Previous medical diagnoses. -------------------------------------------------------------------------------------------------------------------------------------------Review of Systems (ROS): General: Weight change, fatigue, weakness, chills, fever, rash, itching, dryness, nail changes, hair changes HEENT, Eyes: Vision, pain, redness, tearing, double vision HEENT, Ears: Hearing, tinnitus, vertigo, earache, discharge HEENT, Nose: Colds, stuffiness, hay fever, nosebleed, sinus, anosmia HEENT, Mouth: Teeth, bleeding gums, sore throat, hoarseness HEENT, Throat: Dysphagia, lumps, goiter, pain, stiffness Respiratory: Cough blood/sputum/color/quantity, dyspnea, wheezing, asthma, emphysema, TB, pneumonia Cardio: High/low BP, murmurs, orthopnea, nocturnal dyspnea, chest pain, palpitations Vascular: Edema, claudication, cyanosis, varicose events, thrombophlebitis, anemia, easy bruising/bleeding GI: Appetite changes, heartburn, nausea, vomiting, abdominal pain, lactose intolerance, diarrhea, constipation, gas, hemorrhoids, rectal bleed, jaundice, bloating GU: Dysuria, nocturia, polyuria, urgency, hesitancy, incontinence, UTI, stones, stream changes MSK: Joint pain, back ache, AM stiffness, arthritis, gout, cramps, proximal weakness, functional limits Neuro: Headache, blackouts, paralysis, seizures, numbness/tingling, dizziness, tremor Psych: Confusion, memory loss, anxiety, depression, suicide attempts Endocrine: Heat/cold intolerance, polydipsia, polyphagia, diaphoresis, thyroid, diabetes, skin color changes Genital: Discharge, itching, sores, STD, hernias, testicular/vaginal pain, masses, interest, function, satisfaction Gynecological: Menarche age, irregular period, period freq, period duration, bleeding between, last period date, menopause age, post-menopausal bleeding, breast pain/lumps, breast discharge, G_P_A_, preg complications Prevention: Vaccines, tetanus, physical exams, Pap/PSA, mammogram, colonoscopy, helmet, seat belt, airbag -------------------------------------------------------------------------------------------------------------------------------------------Presentation Format – 33 Items In 3 Minutes (Davis 2000, “Asking Answerable Clinical Questions”) 1) Patient’s name 8) Its quantity, intensity, and degree of impairment. 2) Patients age 9) Its chronology: when it began, constant/episodic, 3) Patient’s gender progressive. 4) When the patient was admitted 10) Its setting: in what circumstances does it occur. 5) Chief complaint that led to admission. Mention: 11) Any aggravating or alleviating factors 6) Where on the body it is located. 12) Any associated symptoms. 7) Its quality.

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Hints – Clinical Rotations

James Lamberg

28Jul2010

13) Whether a similar complaint had happened 23) The pertinent physical findings on admission. previously. If so: 24) The pertinent diagnostic test results. 14) How was it investigated? 25) Your concise, one-sentence problem synthesis. 15) What the patient was told about its cause. 26) What you think the most likely diagnosis is. 16) How the patient had been treated for it. 27) And the other items in your differential diagnosis. 17) Pertinent past history of other conditions with 28) Any further diagnostic studies you plan to do. prognostic significance. 29) Your estimate of the patient’s prognosis. 18) How those other conditions have been treated. 30) Your treatment plans. 19) Family history, if pertinent to complaint or 31) How you will monitor the treatment. hospital care. 32) What you will do if the patient doesn’t respond to 20) Social history, if pertinent to complaint or the treatment. hospital care. 33) The educational prescription you would like to 21) Their: ideas (what they thing is wrong), concerns, write for yourself to better understand the patient’s and expectations. disorder in to become a better clinician. 22) Their condition on admission: acute/chronic, severity, requesting what sort of help. -------------------------------------------------------------------------------------------------------------------------------------------Official “Do Not Use” List Potential Problem Preferred Term U (for unit) Mistaken as 0 (zero), 4 (four), or cc Write "unit" IU (for international unit) Mistaken for IV (intravenous) or 10 (ten) Write "international unit" Q.D., QD, q.d., qd (daily) Mistaken for each other Write "daily" Q.O.D., QOD, q.o.d, qod Period after the Q mistaken for "I" and the Write "every other day" (every other day) "O" mistaken for "I" Never write a zero by itself after a Trailing zero (X.O mg) Decimal point missed decimal point (X mg) Always use a zero before a decimal Lack of leading zero (.X mg) Decimal point missed point (O.X mg) Can mean morphine sulfate or magnesium Write "morphine sulfate" and MS, MSO4, MgSO4 sulfate "magnesium sulfate" > (greater than), < (less than) Mistaken for 7 (seven) or "L" Write "greater than" or "less than" Abbreviations for drugs Misinterpreted (similar abbreviations) Write drug names in full Apothecary units Unfamiliar, confused with metric units Use metric units @ Mistaken for 2 (two) Write "at" cc (for cubic centimeter) Mistaken for U (units) Write "ml" or "milliliters" µg (for microgram) Mistaken for mg (milligrams) Write "mcg" or "micrograms" -------------------------------------------------------------------------------------------------------------------------------------------Disconfirming Responses That Block Communication Category Explanation of Category Examples Using pseudo-comforting phrases in an attempt to "It will be okay." "Everything will work False reassurance offer reassurance out." Making a decision for a client; offering personal "If I were you I would…" "I feel you Giving advice opinions; telling a client what to do should…" "You ought to do…" Making an unsubstantiated assumption about what a "What you really mean is you don't like False inferences client means; interpreting the client's behavior your doctor." "Subconsciously, you are without asking validation; jumping to conclusions blaming your husband for the accident." Expressing your own values about what is right and "Abortion is wrong." "It is wrong to Moralizing wrong, especially on a topic concerning the client refuse to have the operation." Conveying your approval or disapproval about the "I'm glad you decided to." "That really Value judgments client's behavior or about what the client has said wasn't a nice way to behave." "She's a using words such as "good," "bad," "nice" good patient." Polite, superficial comments that do not focus on "Isn't that nice?" "Hospital rules, you Social responses what the client is feeling or trying to say; use of know?" "Just do what the doctor says." clichés "It's a beautiful day."

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Hints – Clinical Rotations

James Lamberg

Complete Physical Exam Abbreviations System PE Documentation GEN (general)

HEENT (head, eyes, ears, nose, throat) NECK CV (cardiovascular)

NAD, AAOX4, WDWN (AAM, AAF, WM, WF) NCAT, MMM, EOMI, PERRLA, b/l TM intact & reactive to light, b/l sclera anicteric, Ø conjunctival injection Supple, Ø JVD, Ø LAD, Ø carotid bruit, Ø thyromegaly RRR, S1S2nl, Ø m/r/g, PMI non displaced/non sustained, Ø HJR, CR < 2 secs, Ø CP

LUNGS

CTA B/L, Ø c/r/r/w, Ø egophany, Ø tactile fremitus, nl percussion, Ø SOB

ABD (abdomen)

Obese, no pulsatile masses, +BS nl x4, Ø high pitched or tinkling sounds, resonant to percussion, Soft, ND/NT, Ø rebound/guarding, Ø CVA tenderness, Ø HSM

EXT (extremities) NEURO PSYCH (psychiatric) SKIN

GU (genitourinary)

PELVIC

RECTAL

Ø c/c/e CN II-XII intact, no focal deficit nl affect, Ø hallucinations, nl speech, Ø dysarthria Intact, Ø rashes, Ø lesions, Ø erythema Male: Ø rashes, Ø penile discharge, penile shaft s masses or lesions, Ø inguinal hernia, Ø inguinal LAD, b/l testicles nl in consistency s hydrocele or varicocele, Ø hypospadias/epispadias Ø rashes, nl Bartholin gland, vaginal mucosa nl consistency s atrophy or discharge, cervical os s discharge Bimanual: Ø CMT Ø VB Ø discharge Ø masses Ø BRBPR, Ø melena, Ø masses, nl sphincter tone, Ø ext/int hemorrhoids, prostate walnut size s nodularity or hypertrophy, Ø prostate tenderness

28Jul2010

PE Description No acute distress, alert, awake, and oriented times 4 to name, place, time, purpose, Well developed well nourished (African American Male, African American Female, White Male, White Female) Normocephalic atraumatic, mucous membranes moist, extraocular muscles intact, pupils equally round and reactive to light and accommodation bilaterally, bilateral tympanic membrane intact and reactive to light, bilateral sclera anicteric, no conjunctival injection Supple, no jugular venous distention, no lymphadenopathy, no carotid bruit, no thyromegaly Regular rate and rhythm, S1 and S2 are normal, no murmurs/rubs/or gallops, point of maximal intensity non displaced and non sustained, no Hepatojugular Reflux, capillary refill less than 2 seconds, no chest pain Clear to auscultation bilaterally, no crackles/rales/rhonchi/wheezes, no egophony, no tactile fremitus, normal percussion, no shortness of breath Obese, no pulsatile masses, normal bowel sounds normal in all four quadrants, no high pitched or tinkling sounds, resonant to percussion, Soft, nondistended/non-tender, no rebound or guarding, no costovertebral angle tenderness, no hepatosplenomegaly No cyanosis/clubbing/or edema Cranial Nerve II through XII intact, no focal deficits Normal affect, no hallucinations, normal speech, no dysarthria Intact, no rashes, no lesions, no erythema Male: no rashes, no penile discharge, penile shaft without masses or lesions, no inguinal hernia, no inguinal lymphadenopathy, bilateral testicles normal in consistency without hydrocele or varicocele, no hypospadias or epispadias No rashes, normal Bartholin gland, vaginal mucosa of normal consistency without atrophy or discharge, cervical os without discharge Bimanual: No cervical motion tenderness, no vaginal bleeding, no discharge, no masses No bright red blood per rectum, no melena, no masses, normal sphincter tone, no external or internal hemorrhoids, prostate walnut size without nodularity or hypertrophy, no prostate tenderness

LYMPH Ø LAD No lymphadenopathy (lymphatic) MSK Normal range of motion, no joint swelling or nl ROM, Ø joint swelling or erythema (musculoskeletal) erythema --------------------------------------------------------------------------------------------------------------------------------------------

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