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The most challenging part of my M3 year was not the medicine or interacting with patients, but working to uncover the unspoken rules and roles of an M3. I will start with 10 lessons learned, then talk about my experience, then finish with the 10 rules for M3 Medical Students. I hope this helps you be a little less lost in the complex M3 clinical year.
Lesson 1: At the start of interacting with every new resident or attending, one should ask what their expectations are for you. This includes what to ask and communicate with their patient. Including, after provider rounds ask specifically if you should tell the patient the specific plan and next steps before speaking with the patient alone. During surgical clerkship ask if they want you to scrub in for the whole surgery, only for certain sections, or just be an observer.
Lesson 2: Each M3/resident is assigned 1-2 patients which means you do not interact with all patients. Only focus on the history and physical exam of those patients. If another patient needs something let the other M3/resident assigned to that patient know. Even if it might seem you are being nice by helping them, it is instead seen as disrespectful, unprofessional, or overreaching because it is not your role.
Lesson 3: You must have good time management through only talking with patients in a set amount of time. Talking to patients longer is not seen as you are wanting to get to know them better but that you do not have good time management. Ask the resident/attending how much time they want you to talk with the patient. In clinic it is usually 5-10min and in the hospital it is usually 15-20min. If you go over time then it makes the clinic late which takes time away from the patient receiving proper medical care from the doctor. It is helpful to put a timer on your watch or phone. In the hospital one can always go back after the resident has seen them or in the afternoon before afternoon rounds.
Lesson 4: When we visit a patient during rounds as a team, you are just a silent observer. You may not ask this patient or the doctor anything when in the patient’s room. If you have a question or idea, write it down and wait until after rounds to let the provider in charge of that patient know. Then let that doctor go ask the patient or do said task for that patient.
Lesson 5: Always finish notes after rounds and before you leave for the day. Ask which resident reads the notes of students and co-signs them. Sometimes they need it in the early afternoon if they are using your notes. It also makes it much faster if you start the note when you are pre-charting.
Lesson 6: Your only assigned job as an M3 is to develop clinical knowledge and practice clinical reasoning. This means if you are not chart-checking, writing notes, or with a patient you should be studying. It is seen as you are trying to gain knowledge and are responsible and not wasting your time. The studying also has to be seen as very obvious like practice questions (uworld), article reading, or physician book reading. If they can’t see your computer screen or you studding then they can assume you are doing something unrelated to medicine.
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Lesson 7: All clinics and hospital have multi-disciplinary teams with pre-defined roles, tasks, and responsibilities. Even though it is important to know what the other members do you are not allowed to assist them. Even if you think you are helping it can be seen as you being in the way and that you don’t know your role or refuse to let them do their job. Helping is not helpful.
Lesson 8: If you do not get a certain information from the patient because of time or simply because you forgot say “I don’t know.” DO NOT make up the information or try to go off of memory by saying “I think…” You either asked or you didn’t.
Lesson 9: One must ask for feedback often and take it without emotional reactions. Do not cry, become upset, or make excuses for your behavior. You should know from previous verbal or written evaluation feedback what you need to work on. Therefore, at the beginning of working with the doctor tell them what you are struggling with and working on. Therefore, when feedback is later given it isn’t a huge surprise. However, there can always be feedback that one don’t expect or catches you off guard. In these situations when taking in feedback where you start to become emotionally triggered, take a deep breath and say “thank you for that feedback, I will work on that.”
Lesson 10: You are not a doctor. You are a student which means even if you think you know something you don’t know enough to be a MD…YET!
I feared that if I constantly questioned my residents or attending physicians I would be reprimanded for not knowing what I was supposed to do. I was not used to asking what was expected of me. However, over the year I learned that they would rather you always ask instead of assuming something needs to get done. I wanted to be seen in a positive light and show I had utility to the team. However, I worked so hard to be helpful that it was seen as the opposite. Therefore, I had to change my skill set from being a “doer” to a highly focused observer.
My life as a female and Mexican-American, has led me to struggle to know my “place” and “role” in society. In response I have striven to do trainings and personal development on communication skills, team dynamics, and leadership. However, this challenge persisted and became prevalent during my M3 year to a point where I had to address it head on.
My initial goal in M3 clinicals was to be as helpful and productive as possible. I had a fear of being seen by my residents and attending physicians as lazy, not caring, or being disengaged in patient care. Similarly, I had a fear of getting in trouble if I did not demonstrate I was working at my 110% or my work was not done to perfection
I grew up in a environment and culture where adults were seen as all knowing and questioning authority was unacceptable. Previous authority figures expected me to predict what they wanted and viewed asking questions as either reluctance to obey or as a sign that I was not listening. I was expected to do things without being told, and if I did the wrong thing at the wrong time I would be punished. When I was confused as to how I should be behaving, I learned to mimic what others do or what has been taught previously until I received feedback through praise or punishment.
Similar to M3 year it seemed that the unspoken rules frequently changed as each day as there was a new resident, attending, or clinical environment. Therefore, in clinical settings I constantly tried to do things without being asked and go out of my way to assist the team in any way I felt I was qualified for.
I also tried to follow suggestions from older learners and emulate others. However, this led me to models my behavior after M4s, residents, or other health care providers who had different expectations and roles. My background as a caregiver, bilingual case manager, and medical assistant easily came out when I began working with patients as an M3 because they made up my first experiences of direct patient care. The responsibilities I took on as part of these jobs became very ingrained, so I fell back on them during my clinical year. However, this was seen that I fell into the position of overstepping boundaries and the roles of others which is un-professional as a M3.
At some point during the middle of my M3 year, I was suggested to directly ask my residents and attending physicians their expectations and roles for me. This was the magical key I had been missing!Being able to work within the bounds of established guidelines helped me understand what was expected of me and what I needed to focus on learning. I learned I thrive under clear communication and expectations because they help me feel safe, so I can focus on my performance. Therefore, it was critical to learn to ask and not assume others’ expectations of me in every new provider interaction. When I did this my evaluations score soared to consistently 5 out of 5.
Initially, while speaking with patients, I wanted to make sure I acquired all the information that I could because I feared that if I missed any information, my attending will be angry with me. Therefore, I would initially take an extensive time with each patient and struggled with time management. Instead of jumping straight into the medical problem I would develop report and show my empathy for their problems. Since I have similarly struggled through health condition, social and health disparities I am motivated to show them the humanistic side of medicine.
It was easy for me to tell patients “I do not know” because I recognized that I lacked a vast degree of medical knowledge. However, when it came to an individuals in authority I become terrified, anxious, and had difficulty clearly stating those words for fear I will be reprimanded and seen as not trying my best. However, with practice it became easier to say “I don’t know.” To my surprise, I didn’t get in trouble and instead was respected for recognizing my own limitations to my knowledge.
Lastly, I used to be hyper vigilant of others negative emotions and body language which led me initially to struggle emotionally. However, once I asked and new their expectations I knew that they would only upset if I didn’t do what they asked. If there was any negativism and I was doing my job, then I learned it was not about me and I tried to not take it personally. I also spent time working on becoming more aware of my body and how my emotions were affecting my cognition. In fact, managing my own emotions and body language was another fundamental skill I developed over the past couple years all thanks to my training in somatics.
10 Rules for M3 Medical Students:
1. Connect with every attending and resident at the beginning of the week to discuss their specific expectations of in regards to patient conversations, physical exam, and extra support to the team
2. Always ask and confirm permission to do anything (even to talk with a patient)
3. Only ask OPQRST questions ONE main problem or procedure they are presenting for and the expected questions the resident has asked me to inquire about.
4. Prioritize listening and observing in clinical settings
5. Only answer the specific question that is asked
6. Study when not with a patient and provider
7. Spend 5 min (short visits) or 10 min (long visits) with each patient and have a timer on watch
8. No counseling, educating patient, or phrases of what they can expect to talk about with the MD (only in OSCE can one do this or with specific permission each time from doctor)
9. When a patient is super confusing say that they were “super confusing”
10. Clearly say “I do not know” and “Sorry, I forgot to ask” to attending or resident
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