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An Attending’s Perspective on How to Succeed on Clinical Clerkships

The first day of any clinical rotation as a third-year medical student can be intimidating. As a new internal medicine attending at a large teaching hospital, I often evaluate trainees, but am still close enough to medical school to remember what it’s like to be in their shoes. Below, I outline some key characteristics that distinguish superlative medical students from their peers. What makes students truly stand out is often not their fund of knowledge or clinical skills, but rather the way they approach their role on the care team. While I focus here on the internal medicine rotations, my advice is to some extent applicable to all specialties.

Be a Team Player

During your clinical year, you will be working with new teams on a regular basis. A part of the unspoken curriculum, integrating into a new team and being well-liked requires exercising emotional intelligence and paying close attention to your interactions with others. This means that you should aim to be perceived as helpful, curious, and engaged without being overly-familiar, bogging down daily rounding with too many questions, or appearing to be a know-it-all and trying to “score points” at the expense of your colleagues. If you feel a fellow student is trying to show you up, the attending and residents almost certainly feel the same way. Let it go. Be yourself, but strive to be your best, professional, hardworking self, and incorporate the remaining advice below.

Take Ownership of Your Patients' Care

You should aspire to know more about the patients that you are assigned than anyone else on the team. Even from day 1, you can and should be familiar with the daily “to-do list” of tasks related to caring for your patient, and your intern or resident can assist you in making sure your list is complete. You should be knowledgeable about your patients’ past medical history, daily lab values and objective data (such as ins and outs, vital signs, new imaging results, etc), the story of their presenting illness, and the overall plan. Ideally, by the end of the rotation, you should know the answer to questions like the following:

  • Did Mr. Johnson diurese with the lasix 20 we gave him this morning? What’s his goal dry weight?

  • Does Mrs. Smith have a primary care doctor? Who manages their meds at home?

  • Did Mr. Biddy get his MRI yet?

  • What was the EBL for Ms. Gonzalez’s surgery?

Examples of good answers to the above include:

  • “He put out 1500cc and he is net negative 800cc for the day so far. We think his dry weight is 80 kg.”

  • “Yes, but they're not in our system. Her daughter lives upstairs and helps with her meds.”

  • “He went down but became claustrophobic so they cancelled the scan. Maybe we can write for a premedication next time, or do a CT instead?

  • “The op note said 200 cc, but his hemoglobin dropped 2 points this morning.”

Furthermore, your patients and their families should see you as one of their primary providers. As the days go by, they should know who you are and see you as someone who cares about them, is their advocate, and knows (generally) what's going on. If patients or families ask you things you feel you cannot answer, always state you’ll find out more and get back to them, rather than pass along inaccurate information or make false promises. Having patients or family members praise you is one of the highest compliments you can receive and lets your team know you are spending time and effort in caring for the patient. In short, let your work speak for itself.

Demonstrate Intellectual Honesty

Never say you did something that you did not, whether it's checking a lab value or performing a certain physical exam maneuver. Always tell the truth. If you are caught in a lie, even a minor one, it will look much worse than admitting to an error or omission. While this sounds obvious, the temptation to say that you listened to that heart sound or asked about family history of cancer when you didn’t can be strong in the heat of the moment. Our profession depends on the trustworthiness of our peers, and you want a reputation as someone who can be trusted, even (or especially) if it means admitting you are wrong or that you forgot to do something. It’s a part of the learning process. Students often think this will paint them in an unflattering light, however the opposite is true. I never hold it against anyone for telling the truth; in fact a student admitting they need to double check that lab value or go back and listen to that murmur makes me trust them more, not less, and I give them points for being honest.

Be an Independent Learner

The excellent student will take the more complicated questions that come up during rounds or patient care, do independent research, and come back to the team or attending with what they find and even more nuanced questions.

Say we are discussing a patient with new afib that was started on warfarin.

  • Resident: “Should we continue her aspirin now that she's on warfarin?”

  • Intern: “Not sure, I guess so."

  • Resident: “Ok, let’s continue it for now."

And rounds go on. The excellent student will go and look up the data behind whether or not someone should be on aspirin and anticoagulation in general, and then apply it to this patient, and come back during a calm period and say: "It came up on rounds whether or not to continue aspirin on that patient. I looked it up and found that since it was for primary prevention, it would be reasonable to hold the aspirin if she is on a blood thinner given the increased bleeding risk and there's no clear data on reducing major cardiac events." The team (who may be overburdened with clinical tasks such that they don’t have time to do this research) will love your initiative.

In addition, part of being an independent learner is seeking out feedback AND incorporating it into your performance. The most common example is presentations. After giving a presentation, ask how you can improve. Take constructive criticism without getting defensive, and implement the feedback in your next presentation. It doesn’t matter what your starting point is; it is normal for your first presentation to be scattered, incomplete, or unnecessarily detailed (you’re here to learn how to improve presentations, after all). It matters more that your last presentation is clearly better than your first. To many evaluators, a trajectory of improvement and willingness to incorporate feedback is just as important as a student’s initial starting point.

Have an Approach for Common Tasks

In medicine, we love having an “approach to” various problems, such as shortness of breath, elevated LFTs, chest pain, abdominal pain, etc. Oftentimes students try crash review common inpatient problems or chief complaints the night before. This is of questionable benefit, as much of this is what you are about to learn, and you are not expected to have mastered it beforehand. I believe the best thing to do the day prior to rotation is not to focus so much on having an approach to medical problems, but instead having an “approach to” a few fundamentals, such as taking a new patient history and physical exam and interpretation of ECGs and chest x-rays.

Why? In the first few days, you will invariably be asked: Why don’t you go see this new patient? or So what do you think about this EKG/CXR? You will likely be nervous and forgetful. If it’s your first rotation, you may have never taken a full history and physical from a real patient without supervision or asked to interpret data on the spot. Having a schema to fall back on in each of these situations is key and something you can prepare for prior to day 1. An excellent student is not expected to nail the correct interpretation of a chest x-ray or EKG in one sentence. At your level, the excellent student goes through them systematically and intelligently. Whether they come to a correct or incorrect conclusion is less important. So whatever schema your school teaches or you prefer, you should have a system to fall back on when asked (i.e., a way to avoid the dreaded “deer-in-headlights” moment).

In summary, an excellent medical student is not necessarily the smartest or most gregarious. The excellent medical student contributes positively to the team dynamic by using their time and intellectual curiosity to take ownership of their patients as much as possible, coming up with answers to interesting clinical questions without explicit prompting, and sharing their research with the team at opportune times. The excellent medical student is respectful to everyone and is seen as trustworthy. The excellent medical student doesn’t just ask for feedback, but responds well to criticism and incorporates action items in real time. The excellent medical student is able to hit the ground running by having a way to approach the basics. While all of this is easier said than done, any dedicated student can cultivate these characteristics with intentional practice and awareness, and you will be well on your way to succeed on your clerkships and beyond.

Dr. Lucas Marinacci completed his internal medicine residency at Massachusetts General Hospital, where is he now an attending physician, hospitalist, and an Instructor in Medicine at Harvard Medical School. He scored a 262 on Step 1 and a 272 on Step 2 CK, and tutors for these exams as well as Step 2 CS and Step 3 with USMLE Pro.

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