Advice for Your Clinical Clerkships
Given that I have had little to do with teaching medical students for the last two and a half years, I’ve had a strange winter. Five students, from four different medical schools, have reached out to me for advice before they start their clinical rotations.1 I’ve come away from every one of these interactions feeling like I failed to give really good advice. So, feeling guilty, I’ve put in a little bit more thought. I hope this is helpful.2
Learn from your patients
OK, this is the least original suggestion anyone can make. You learn best when knowledge is linked to a patient. I can’t remember what I read in the NEJM last week but I remember everything that I learned about cirrhosis when I took care of JR as a medical student. Every night, I read about the causes of hepatitis and the physiology of portal hypertension. Every day, I examined his jaundiced sclera, his ascitic belly, his spider angiomas, his plethoric palms, and his caput medusa. Every other day I tapped his belly. I – remember -- everything.
Keep an open mind
Immerse yourself and believe you can do, and love, everything. No medical student has enough experience with the diversity of medical specialties to know what he or she wants to do in the future. I have lost count of the number of aspiring orthopedic surgeons and ophthalmologists who end up as pediatricians, internists, and psychiatrists. And, even if you do follow your dream and become an orthopedist, it is pretty helpful to know a lot of medicine, pediatrics, dermatology... (Oh, and your evaluators will instantly sense if you don’t care.)
If anyone asks you what you’d like to learn, ask them what they like to teach
If you ask me to teach you about defibrillators, you’ll get my summary of what is on UpToDate. If you let me tell you about diagnosing a headache, you’ll probably learn something.
It is not about you
Yes, you might be paying a heap of tuition. Yes, you are in school to learn. Yes, you are used to being taught. But on a team in the hospital, your education is the lowest priority. Your clinical rotations are about mastering practice-based learning. This is how you should learn on the wards and how you will learn for the rest of your career. From now on, you are responsible for your own education.
Volunteer to do extra work
You are the team member with the least work and the least responsibility. If you volunteer to do more you will learn more, be more involved, be given more responsibility and you will have more fun. Put yourself in difficult situations. You can always play the medical student card: “That is an excellent question. I am sorry I can’t answer it. I am just the student. Let me go find somebody that can.”
Get to know the patients better than anybody else
Because you have the least amount of work of anyone on the team, get to know the patients the best. Spend extra time with your patients when you admit them. Spend extra time with them on rounds. See them before you go home. You are unlikely to make a great diagnosis or come up with a transcendent treatment plan but you may change the course of a hospitalization through the bonds you forge or the information you gather.
Ask after your classmates
Your clinical rotations will be hard. They are supposed to be. You will be caring for people during the worst days of their lives. You do not know enough to do the job you are expected to do. You might be evaluated harshly, and potentially unfairly. Support your colleagues and help them when they need it.
Learn from everyone
Everyone has something to teach you. There will be residents and attendings who are obviously role models. There will be many others who are not. Learn from them too. Notice the things they do well. Recognize what they do poorly. Learn from the nurses, the pharmacists, the physical therapists, the chaplains, the sitters…
Establish good habits
If a patient asks for a glass of water, get it for her. If you say you will come back with information, go back, even it if means apologizing that you don’t have the information. Spend the extra time with a patient who needs you to. But, if you find yourself coming home late every night, and your dog is starving or your partner is angry, figure out what you are doing wrong.
Take the long view
Residency is short, your career is long. Think about life after residency. Choose the field that will bring you joy, not the field the idea of which you like. Find your people. The people who make you feel at home are in the field that is your home. Discover the field with the “bread and butter” that you love. You’ll be thinking about, talking about, and teaching patients about this every day.
Ok, that is better than what I said to the students when I muddled through a response. I hope this is helpful. There are a lot of wise people among our subscribers. Please chime in in the comments – help train our next generations of doctors.
We’ll call that the Sensible Medicine effect.
Though if it is helpful, it will lend credence to my concern that I am much more pithy on the page than IRL.
One of my most important early lessons occurred when I was working as an intern in the ER in 1968. A lady brought her son in for what clinically was c/w Strep throat. After examining the patient and speaking with the Mom, I wrote an order for a penicillin injection. Immediately after it was given I panicked because I had not asked her about penicillin allergy. I then asked the mother what reaction had occurred and what was done. She didn't remember all of the details so I explained to her what my mistake was and told her we were going to watch her son in the ER for several hours where we could treat him if any allergic reaction symptoms occurred. We kept close tabs on her son near the nurses desk (I went in to see him often). He did very well with no new issues and was discharged home several hours later. She thanked me for being honest and ultimately sought me ought over the next year to ask for advice about some of her son's additional medical concerns. It was certainly not the only mistake I made during my career, but it did teach me that patients are much more likely to be forgiving and tolerant when you are honest about your own errors.
A few thoughts, and these echo some of the other comments you have received: Learn how to think. Clinical reasoning is not emphasized in the learning (and I am afraid, often in the teaching) of medical students. Clinical reasoning is not the same as finding an answer to the attending's question on your phone on UpToDate or whatever reference you are using while you are still at the patient's bedside. I agree with the comment: history is 90%, physical exam is 10%; but that's what separates B's from A's. It irks me to hear or read that physical exam is not important anymore, just order labs and imaging. How do you know what labs and imaging to order until you have put history and PE together? And finally, lets put a finer point on the student's greatest opportunity. The student (especially MS3) is the member of the team with the least work load and the most time at the end of the day. Go back, spend time with your patients, sit with them at their eye level, not looking down at them from standing; hold their hands, get to know them, let them tell you the stories of their lives, shed a few tears, let them know you see them as real people, not just as patients. Whatever specialty you go into, this is what the practice of medicine is all about, this is where you will find the most joy and the greatest reward.