How to be a Good GREAT Third Year Student on the Wards…Debra Bynum, MDPrior 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 yearHer board scores were out the roof…She always out-answered the other studentShe 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. Knowledge2. Good ICM Skills3. 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 ASSUMEDo not assume that what your patient needs will actually get doneDo not assume your team knows what you doDo not assume to know what your team expects Do not assume your patient knows what is happening

ASKAsk about callAsk about pre-roundingAsk what patients to pick up on first dayAsk about conferences, schedulesAsk about notesAsk how you can help

What can I do to make a good impression?

Be positiveBe pro-active: Offer to do what is needed before you are askedOffer to do small presentations for the teamLook up articles for the team and shareHelp 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 presentationsIf you are bored, do not look bored…Ask the right number of questionsBe availableRead about your patientsAsk to help out with notes, orders, forms

What can I do….Ask to help out with clinical “scut” work:

Pulse oximetry with ambulationMake sure patient gets to their test (go with them)If they need to be NPO, make sure they areMake sure a patient gets up out of bed to a chairGet orthostatics when neededBring samples down to the lab in acute eventsScrub in for surgery and procedures

Follow UpMake sure the plan for your patient is carried out

Do not assume it will happenAsk the nurseCall down to the procedure siteMake sure transportation happensLet your resident/intern know if there is a problem

What can I doBe 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

Each morning….

Check the MAR for current medications

Pre-roundingInformation to know: “Attachments”

IV and Central linesFoley cathetersTelemetry boxRestraintsSCDs

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

ResponsibilitiesPrepare 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

ResponsibilitiesKnow your patientKnow ABOUT your patient

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

ResponsibilitiesAfter Rounds

Keep a “to-do” listStay organizedFollow up on the to-do list!Be available!! Let the team know if you have a student conference or meeting you have to attendSign out before leaving, go over list, updates and any other needs

ResponsibilitiesYour goal is to learn and improveAsk for Feedback

internsResidentsAttendingsPatients/families

Notes and Presentations: SOAPSubjective

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 statementStick to the Problem List

PlanTalk to your resident/intern beforehandHave a plan for the day!!

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

Other tips for the presentation

Stick to the formatStick to the problem listRun the plan by your intern/resident before roundsHave a plan

The LookWear your white coat and badge

Things to carryNotebook with patient information, pensRounds report for patients on your team (even patients that are not “yours”)Clinical “pocket” book for the rotation (ask)Sanford guide/pharmacopeiaScissors (esp on surgery)Reflex hammerLightStethoscope

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 residentRed Flags:

FeverIncrease pulse rateShortness of breathChest painIncrease in respiratory rateDecrease in oxygen saturationChange in mental statusDecrease in blood pressureSevere 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 FunLearn a tonHelp a patient