How to be a Good GREAT Third Year Student on the Wards… Debra Bynum, MD Prior third year UNC Medical Student (1992)

Heard in the physician work room this last week…. She is a really good student… One of the best I’ve worked with all year…. (from a third year internal medicine resident….)

WHY?

From the Resident… She was always available She always had a great attitude She always read about her patients She always did things to help; she did not disappear in the afternoon to study for her tests… She picked up more patients than assigned; even patients she did not pick up, she came to the ED with us to see the patient, learn, and just to help She understands the “big picture” She is great with patients and families

What the resident did NOT say… She got all honors for second year Her board scores were out the roof… She always out-answered the other student She knew all the answers

Bottom Line: The Good and the Bad Attitude and energy can make or break you What you know is important, but how you act and demonstrate your knowledge is even more important Excellent first and second year medical students may not always have an easy time during third year (subjective evaluations) Students can shine during clinical years

What makes a good student? 1. Knowledge 2. Good ICM Skills 3. Kindergarten Skills

Bottom Line… If you energetically try to provide the best care for your patients, you will be a good student and a good doctor

What does this mean? Know your patient well Read about your patient’s problems and learn how to take care of your patient Make sure your patient gets good care – be their advocate Communicate your patient’s needs to the team

About “Scut” There is NO scut work related to the care of your patient If your patient needs a lab draw, vital sign, form completed, help getting out of bed – then it is important The story of Dr. Parker….

DO NOT ASSUME Do not assume that what your patient needs will actually get done Do not assume your team knows what you do Do not assume to know what your team expects Do not assume your patient knows what is happening

ASK Ask about call Ask about pre-rounding Ask what patients to pick up on first day Ask about conferences, schedules Ask about notes Ask how you can help

What can I do to make a good impression? Be positive Be pro-active: Offer to do what is needed before you are asked Offer to do small presentations for the team Look up articles for the team and share Help interns, residents and other students on the team

What can I do…. Go and see and evaluate as many patients as you can – even those patients you will not be “following” Ask about call: If overnight call is not required, offer to stay late or overnight for at least one call night for each rotation

What can I do… Dress neatly and appropriately Do not chew gum Do not carry food or beverages on rounds Always be professional, even if others are not

What can I do… Pay attention on rounds, even to other patients and other presentations If you are bored, do not look bored… Ask the right number of questions Be available Read about your patients Ask to help out with notes, orders, forms

What can I do…. Ask to help out with clinical “scut” work: Pulse oximetry with ambulation Make sure patient gets to their test (go with them) If they need to be NPO, make sure they are Make sure a patient gets up out of bed to a chair Get orthostatics when needed Bring samples down to the lab in acute events Scrub in for surgery and procedures

Follow Up Make sure the plan for your patient is carried out Do not assume it will happen Ask the nurse Call down to the procedure site Make sure transportation happens Let your resident/intern know if there is a problem

What can I do Be on time for rounds, lectures, meetings Do not try to make the others look bad Be nice to staff, nurses, HUC’s Be respectful to and of patients, families and visitors

What are my responsibilities as a third year student?

Pre-round on your patients What is needed will vary by clerkship Anticipate 10-15 minutes per patient (longer initially) Touch base with your intern or resident

Each morning…. Vitals Overnight events (from nurse and overnight intern/float): TALK TO THE NURSE Subjective issues from the patient Physical exam findings (for the day) Labs and other data Consult reports from prior day/evening Any radiology/tests that came back the day before

Check the MAR for current medications Each morning…. Check the MAR for current medications

Pre-rounding Information to know: “Attachments” IV and Central lines Foley catheters Telemetry box Restraints SCDs

Responsibilities… Develop your problem list with a plan for the day for each problem Record the above data each day – this can serve as a template for your morning presentation and progress note Meet with the intern/resident before rounds to review plans for your patient

Responsibilities Prepare your oral presentation (practice) Present to the team on rounds (3 minutes) Keep follow up sheets of data in large, spiral bound notebook so you have easy access to prior days, labs, medications, etc (It is NOT cool to have thousands of cards flying out of your pockets on rounds….) Help write progress notes, orders, discharge notes, prescriptions Be the EXPERT on your patients

Responsibilities Know your patient Know ABOUT your patient Read about all of the diagnoses for your patient Know the anatomy before going into surgery Anticipate questions (“Pimping”) Don’t freak out about “pimping” – it is an excellent way to learn when done correctly

Responsibilities Keep a “to-do” list Stay organized After Rounds Keep a “to-do” list Stay organized Follow up on the to-do list! Be available!! Let the team know if you have a student conference or meeting you have to attend Sign out before leaving, go over list, updates and any other needs

Responsibilities Your goal is to learn and improve Ask for Feedback interns Residents Attendings Patients/families

Notes and Presentations: SOAP Subjective Patient complaints, overnight events, pertinent positive and negative ROS Eating, pooping, peeing, walking…. Objective: Vitals (fever, ins and outs, oxygenation) Physical exam (pertinent findings and changes) Labs, xrays, studies

SOAP…. Assessment Summary statement Stick to the Problem List Plan Talk to your resident/intern beforehand Have a plan for the day!!

KNOW MORE THAN YOU WRITE, WRITE MORE THAN YOU SAY…

Other tips for the presentation Stick to the format Stick to the problem list Run the plan by your intern/resident before rounds Have a plan

The Look Wear your white coat and badge Things to carry Notebook with patient information, pens Rounds report for patients on your team (even patients that are not “yours”) Clinical “pocket” book for the rotation (ask) Sanford guide/pharmacopeia Scissors (esp on surgery) Reflex hammer Light Stethoscope

What if….

What if my patient looks really sick when I go to pre-round Use your gut – if someone looks really sick, call your resident Red Flags: Fever Increase pulse rate Shortness of breath Chest pain Increase in respiratory rate Decrease in oxygen saturation Change in mental status Decrease in blood pressure Severe pain

What if… The nurse is really concerned or worried… Go get your resident or intern; trust the nurse’s instincts as well as your own

What if… You Have Fun Learn a ton Help a patient