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Clinical Rotations in Medical School: The Hidden Curriculum
Transcript: Tips for Medical School Clinical Rotations Part 1
Stephanie Moss, MD: As a medical student your Job your role is to gather history, is to ask the questions, not to give the answers .Which is confusing because you spent so much time Giving the answers. I think that is why it's so confusing about M3 clinicals. For the past two years Attending, teachers, UWorld questions have constantly been asking you questions and so you're quickly supposed to have an answer, but the real world doesn't work like that.
There's not always one right answer. And so it's hard when a patient asks you a question, you feel Or you may feel that you want to answer the question you want to feel helpful. You want to feel knowledgeable. And like I said before, unfortunately, that is seen poorly, because we really don't know everything, even though we've been spending the past 2, 3 years.
Thinking like we do, being a lot of our knowledge, intelligence is seen based on how well you answer the questions, how quickly you can answer the questions. If you answer it correctly, and when a patient asks you a question, Not necessarily do you know the right answer. Even though it might seem like you do. what are the most challenging parts of the M3 year? It's not the medicine or interacting patients, What I'll be talking about are the unspoken rules, or also called the hidden curriculum, which includes the specific roles of the M3 students.
My name is Dr. Moss from Life as a Patient Doctor. Today I'll be going over the blog post, Navigating M3 Clinical Year, 10 Lessons Learned.
You can see it on https://medpsycmoss.com/blog/clinical-rotations
I will start with 10 lessons learned through my experience. Then I'll talk about my [00:02:00] specific experience and challenges that I encountered. Now, granted, this was now two years ago, so things might have changed Since I was an M3, I'm currently a PGY1 psychiatry resident, however, I have M3 students that I mentor, and also on rotation as a resident, and from talking to them, it seems to be pretty similar, and this is also, I do want to say, This experience was also specific to my medical school.
Granted, every medical school is different on how they do clinicals, but that's, but a lot of these concepts, especially when we're talking about the hidden curriculum of medicine, seems to be pretty consistent and just part of the big system of medical education. So after I talk a little bit about my experience, and obviously when I'm doing the podcast, I sometimes go beyond this blog post and start getting my own experience and little things that I remember, but you know how it goes.
And then I'm going to be giving specific 10 rules for M3 students. So [00:03:00] I hope this helps you if you're just starting m3 clinicals Or if you've already done a couple months and still feel a little lost. I really hope this helps you And of course and i'm actually recording live Are live on instagram. So if you if But at any point I say something that, or you have any, a different question, please put them because I want this to be helpful for you. Okay.
Lesson 1: Setting Expectations
Starting with the 10 lessons learned. Lesson one. At the start of interacting with every new resident or attending, one should ask what their expectations are. This includes what to ask and what to communicate with their patient. For example, some providers might want you to ask something specific to them as their specialty or just something that they're specifically interested in.
That is one reason. Also, sometimes this includes timing. Sometimes they only want you to see a patient for five or ten minutes. And as a medical student, it's really easy to do longer than that. So do shorter hope that helps.
And then including after provider rounds, ask specifically if you should tell the patient the specific plan and next steps before speaking to the patient alone. Oh my goodness, I remember this. I had an example where I thought it was our job, since we talked in a group after we round with the attending and the residents, I thought it would be helpful to like, go tell the patient what our plan was.
Some attendings like that. But the majority do not like it. They like to make sure that they are with you or they're the ones telling the plan. Because plans can change. Sometimes you misunderstood what they said. Or sometimes by the time that you get back to the patient's room, or let's say like an hour later, new results come in, which completely changes the plan. Also, since you're a medical student, you don't always understand all the medications, all the diseases.
And sometimes they ask you, like the patient asks you questions that you don't know. And that's why it's important to ask the residents, like how much they want to disclose. I remember I was in OB GYN clinical rotation, and I went in to the patient room, wanted to have birth control and so I started doing what we were taught to do in OSCEs.
Where it's like, what type, like asking them questions. About in addition to just gathering history, I started educating them on every single type of birth control, and my attending really did not like it. She got very angry with me. And that's why I learned oh, I should have asked her if she wanted me to educate the patient on different birth controls.
Did she want me to just gather history? Did she want me to just be like, cool. You're here for birth control and go back. That's what she wanted. Now, if you are a resident or attending, please talk to medical students and tell them what you expect, even if they don't ask you, because they're constantly going in and out of different providers, different residents, and everyone has their own expectations.
It's hard and I wish I could obviously tell the attendee and don't be upset if the resident, if the medical student makes a mistake. That's what they're in for. They're here to learn. So yeah, I hope that helps. Thinking about surgery. Surgery rotation. Sometimes the residents don't want you to scrub in.
So not all the times do the attendings want you to scrub in. Sometimes they just want you to observe. And very simple, if you ask beforehand, then you can find out what they want.
Maybe they only want [00:07:00] you to scrub in halfway through. You never know. And it's better to ask beforehand instead of them being upset with you after. Been there, done that, not fun. Okay, next we're going to talk about
At the beginning of interacting with residents or attendings, always ask what their expectations are. This includes understanding what to ask and what to communicate with the patient. For instance, some providers may only want you to spend a limited amount of time with each patient. Clarifying these expectations early on can save you from potential misunderstandings.
Lesson 2: Working with Patients
Each medical student is assigned specific patients, which means you do not interact with All the patients. This lesson I learned when I was in psychiatry inpatient, because I thought that when we did group rounds, that we would all, I thought since we all go in a room, I thought we like, all talked to patients.
That was originally, when I was at the beginning of my M3 year, and no, it's supposed to be only the medical student and the resident signed. They're the only ones who can open their mouths. That includes if attending asks a question.
They are the only ones who can talk to the patient, get a history on the patient, follow up with the patient.
Now, thinking about it, okay, this is, One, because it gets confusing if you are the patient and suddenly you have five different doctors come in, medical students, it gets confusing and if you've ever been in the hospital and they keep asking you the same question over and over, it gets annoying.
Like thinking about it from a patient's perspective, it gets really annoying to be saying the same thing over and over and over and over. So that's one reason. Second reason going back to being a med student, you don't know all the things yet. You don't know all the medicine yet.
And you don't want to say anything that's wrong from the hospital perspective, something that someone can sue you for or the hospital for. So these are part of the reasons why they have so many rules or, unfortunately, like I said, this is a hidden curriculum. They don't actually tell you these things.
You just have to find out through error, through practice and error. So hopefully that helps. We're only assigned a couple patients at a time. If another patient asks you for something go figure out who's the medical student or the resident who's assigned to that patient. You can say oh i'm not your medical student, but i'll go find your doctor I'll go find the person that will know more information. Just like if A patient had a question that you don't know as a doctor.
Let's say you are like me, a psychiatrist, and a patient asks you a question about their regular health care. I'm not, if we're on the general medical floors, I'm not their main . I'm their consult. So I'll say, I don't know. I will go talk to the person that is your main team to help you.
That's why it's important to go check in. I do want to say like even if it seems nice that you're helping them It's more nice if you help them understand What it mean, it's more helpful if you connect them to the right (provider). Even though you might think oh, maybe I know the answer or maybe I could help.
I will give the example when I was, what was this, internal medicine. There was a patient that needed transport. I think they were going to like a CT or something, and the transport team wasn't here yet. I was like, oh my god I can help. I'm not doing anything, like I can help push a cart.
I thought I was being helpful. I was not. Later got in trouble and yelled at by the attending. The residents were helpful and were like, oh yeah, look at how helpful you are, but I got in trouble. Why did I get in trouble? Because That is not my role, and we'll be talking about that a lot throughout, is M3 clinicals is really hard because you're trying to figure out where is my role?
And, in the hospital, there are people that are paid to be transport. They know how to safely maneuver the carts and beds. So think about it from the safety perspective of even if maybe you were a EMT or maybe you were a transport before because this happens.
Still, the hospital doesn't like it because you could hurt a patient. They could sue you, blah, blah, blah. Anyway, so that's a good reason why it's not helpful and you think it is.
Okay, let's see what else in regards to lesson two.
I really need to write I think that's actually going to be one of my next article blog posts I write. And I was recently accepted as a Doximity Fellow where I get to write articles. So I'm going to write on
being seen as "unprofessional" and that word is used a lot in a positive way and in the not positive way in medicine a lot. So this is like a sneak peek, but a lot of times when these invisible rules aren't followed, it is seen as unprofessional. And you can get. An unprofessional write up, which is really sad that is used as a weapon instead of a teaching moment.
So I'll talk about that later, but I guess the overall lesson for this second lesson, is only focus on your patients that you are assigned to. Only talk about your patients you're assigned to. Only talk to and about the patients.
Each medical student is assigned specific patients. You should only interact with and talk about these patients to avoid confusion and ensure accurate information is being communicated. This practice also respects the patient's experience, preventing them from being asked the same questions repeatedly by different individuals.
Lesson 3: Time Management
Lesson number three, having good time management. We talked about this in number one, but I'm going to bring it up again. So you must have good time management through only talking with the patients in a set amount of time. Talking to patients longer is actually not safe. It's not seen as a positive thing, even though you would think it is especially when you're early in your medical career, you think oh, I'm trying to get more information.
But it's not actually, it's not seen positively by the residents and attendings. And this is why. It's actually seen as not good time management. That's another word that unfortunately part of the hidden curriculum. And things that you learned in the OSCE, of do the HPI, of ask the patient about every single review of system.
Ask the patient about every single new symptom they bring up. Even though we seem to be taught that, for the OSCE when we're in real patient situations, it clouds, the patient time so you don't have enough time with the patient. And when we're talking about in clinic, since clinics are scheduled unfortunately for only 10 or 15 minutes at a time.
if you as a medical student take, let's say 10 or 15 minutes, you just used up the entire patient time and attendings sometimes get pretty upset because then they can't get to the patient and all their other patients keep getting pushed farther and farther behind.
So this is where it jumps back to lesson one of ask the expectations. Ask the attending, like, how long do you want me to spend with patients? What questions do you want? What should I prioritize? So hopefully that's helpful. One of the attendings that I worked with in family clinic.
Said aim for 5 to 10 minutes if you're in the clinic, and 15 to 20 minutes if you're in the hospital. Now, obviously, that's not for every rotation, not for every attending. In psychiatry, we do get longer, sometimes they expect like 30 minutes And I think that's also helpful to going back to the expectations to see
If the resident wants to see them with you.At first I remember I felt a little bit awkward with having them watch me because I was like, Oh, maybe they're judging me. But it actually helps as a resident because one, we can see how you interview.
We can help if the patient has any additional questions. And three, sometimes the notes that the medical student writes do not even count at least for billing purposes, and so it's hard for the resident because they have to wait till the medical student comes back and then they have to do it themselves.
And so that's if the resident comes with you, the medical student, don't see it as a negative. See it as like a helpful thing that they're just trying to do their job so they can also write the note. Now sometimes medical school slash residencies are okay if like medical student writes a note and then resident addends it or edits it is another way to say it and then we send it to the attending.
Now let's see that I said everything regards to time management. A good way to stay on track is to put a timer on your phone. So that means that you can put like a 5 or 10 minute timer. That sometimes helps. If it goes off, maybe you can even make a joke with the patient.
Sorry, only have five minutes. Thank you for spending five minutes with me. Or I want to help you, but I only have limited time before my resident comes in or before my attending comes in. So what is the most important thing you want to talk about today? That's some things that will help you stay on time, but also show the patient that you care about them, that You value their your time and it also helps them feel Supported. Oh, this is also good to know. Going Back
So If you're in the hospital, a lot of this is regards to pre rounding you can always go back in the afternoon and check in how the patient's doing or ask them more. A lot of residents like that because it shows initiative and shows that you remember that you still have a patient, which is important because a lot of times in the afternoon, we spend so much time doing notes.
And the thing is, a lot of time has changed from the morning patients to like the afternoons, because, we've done lab orders by then maybe they received new medication. And so that's like a little bonus point that you can use as a medical student. You can always ask cause we talked about before Hey, is it okay if I go ask the patient or is it okay if I go ask how they liked that new medicine or what they felt after lunch or if they've had a bowel movement yet, if you're on internal medicine, they ask that all the time after surgery: have they passed gas? Have they urinated yet? So those are all simple questions.
Good time management is essential during clinical rotations. While it may seem beneficial to spend a lot of time with each patient, it is often seen as inefficient. Ask your attending how long you should spend with patients and prioritize your questions accordingly. Using a timer can help you stay within the expected timeframe, showing respect for the patient's time and the overall clinic schedule.
Role of a medical student
That is gathering history And I'm sure we're going to do that in the other lessons or maybe rules, you as a medical student your Job your role is to gather history is to ask the questions not to give The answers which is confusing because you spent so much time Giving the answers.
Maybe, you know what, as I'm saying that, I think that is why it's so confusing about M3 clinicals. For the past two years Attending, teachers, UWorld questions have constantly been asking you questions and so you're quickly supposed to have an answer, but the real world doesn't work like that.
There's not always one right answer. And so it's hard when a patient asks you a question, you feel Or you may feel that you want to answer the question you want to feel helpful. You want to feel knowledgeable. Unfortunately, that is seen poorly, because we really don't know everything, even though we've been spending the past 2, 3 years.
Medical Knowledge Fallacy
Thinking like we do, being a lot of our knowledge, "intelligence" is seen based on how well you answer the questions, how quickly you can answer the questions, if you answer it correctly, and when a patient asks you a question, Not necessarily do you know the right answer, even though it might seem like you do.
There's always little things in real life that maybe make it not 100%. I know that this is actually even a challenge that I deal with right now as a resident. Since I've now spent four, five years. Working to answer the questions super fast in step one, step two, almost in step three.
And so I want to give the answer or say Oh, based on these symptoms, the patient has this diagnosis. So for example, I had a patient come in that seemed on in textbook, like the first manic episode of bipolar. And I was so excited and then I told my attending and resident and they're like we can't come to that diagnosis so quickly.
And at first I felt very bad because I'm like, wait, does this mean that I don't know information? Does this mean I'm not intelligent enough? Do I not deserve to be in residency? But the thing is in real life, in real clinic, we have to give patients more time to show symptoms. Everyone is allowed to show different symptoms at different times and not all the time should we make the diagnosis right away.
Sometimes it's helpful to see them over a couple of days, put them in- patient, put them in the hospital, wait for lab values, make sure it's not something else. And I, that is one of the hard things about medical education. And you know what you see I'm already giving a lot of like additional lessons from m3 instead of following with my blog post.
Like yes when we're a student we're supposed to give differentials to the health care provider: the attending or resident. So that's important to do [00:21:00] after you've seen the patient, is say, Look, I think it could be X, Y, or Z. And it's most likely X. And then as a resident, I still, I think, do the same thing, but instead of sticking to one answer, I'm supposed to say, but I'm going to do way more diagnosis more workup instead of just jumping on an answer.
And that is hard and it's something that I myself are still learning as a first year resident. So hopefully that helps you. Let's go to the next one.
Lesson 4: Group Rounds Etiquette
So lesson number four. When we visit a patient on group rounds, so that's usually morning, you are just a silent observer. Unless they've told you that you can introduce the patient to the rest of the team. That is really important to know.
And it goes back to asking the attending beforehand. In group rounds where the attending goes, the resident, the medical student, and sometimes you have nursing there, sometimes you have other consults there,
You've already presented the information that you've gathered. So it's best to start with just thinking. I'm silent. I'm listening again. It's part of the hidden curriculum because it seems a lot of times you feel like you need to be talking. Sometimes attendings want you to do that: they have you introduce the patient to the team or talk about the patient in front of the patient or explain what we talked about.
But that goes back to lesson number one. Ask expectations. What do the residents and attendings like? Do they want you to do that or do they want you to go into a corner and just zip and listen? And so , that was specifically talking about if that's your patient. If it's not your patient, we already talked about this earlier, you can't say anything and that is hard.
I think it's one of the reasons it's so hard is because Maybe if you have marginalized identities, like myself as a Latina and a female, you feel like if you're not saying something, your silence maybe makes you feel like you don't know the answer. And being in this environment, you don't know the answer.
And even if you do , this is not the the environment where they want you to show that you know the answer and It's hard because sometimes the attending asks the question and maybe will look at all of you. If they do address you specifically, sometimes they'll point you out say something like that.
But usually when an attending asks, the question is more directed to the specific med student or resident that is, In charge of the patient. Oh, that reminds me. This was really Weird and confusing because I've never seen this before it goes by rank sometimes when an attending asks a question
They willdirect the question at the medical student if the medical student doesn't know it or they say something, then they go up to the next person in rank order.
So that would be the fourth year medical student, if there's one. And then if they don't know it, or they provide an answer, but the attending wants more information, then they'll go to intern, second year, third year, fourth year, fellow, , that's usually it.
But that was really weird the first time and you know what I remember the first time I saw that happen was in pediatrics inpatient where they asked me, they asked a question of me and then they moved on and I thought that meant that I got it wrong or that They thought that I wasn't smart enough and that was really hard for me.
And so know that's not the case Just as you go up in the level That's how the attending makes it a dialogue. It's actually something we're taught as residents. When have a question don't have one a yes, no answer and two make it, There's actually a word for this, socratic.
And so they will go from one person to the next and next. It's actually part of the training and part of a good doctor or good resident and good teacher and educator to go up and make it harder and harder. To make it harder for each level of learners. So I hope that helps in regards to thinking, or if asking why they keep moving around.
It's not that you got it wrong, or maybe it is, but that's okay, that's why you're here. Don't take it as you are not smart enough or good enough . Okay, now let's talk about lesson number five.
During group rounds, you are primarily a silent observer unless instructed otherwise. Familiarize yourself with the expectations of your attending or resident beforehand. If they want you to introduce the patient or present information, follow their lead. Remember, your silence does not reflect your knowledge or competence.
So lesson five, Always finish your notes after roundings and before you leave for the day.So this kind of go back to number one about expectations.
Sometimes they don't even want you or need you to write a note. If you don't need to write a note, why put in the effort to do that? Ask them what time they want you to have it done, because there are some places or some residents that do use your note, at least as information, what you gathered.
In some places, they're not allowed to do that. I remember I learned this lesson in my psychiatry rotation where unfortunately, I had an intern resident who got very upset with me and actually even wrote me up because I didn't submit the notes until the following morning. I had stayed Till seven o'clock at night.
So like super long calling the patient's mother Spending all this time writing note, but I didn't think it was perfect or ready And so I was like, oh i'll finish it tomorrow morning. And she got very upset and even reported me to the M3 clinicals, and I got written up for it, for being unprofessional, for not turning in my notes on time.
But there you go I did not ask beforehand, nor know what time she, my resident that I was working with, wanted me to have the notes in by. So all that hard work I did didn't even matter. So it's important, even if they don't have a preference . Just try to get your notes in before you leave and that will hopefully save you a headache and hopefully not get in trouble like me.
You notice I do seem to get in trouble a, lot so I'll talk about why I'm talking about this: following the hidden curriculum. It's important to talk about. Sometimes I need them early in the afternoon so the resident can use, sometimes it's just Before the night time, sometimes before four o'clock, if the resident maybe leaves at four o'clock and they have to addend them or at least read them, always important.
Pre-Rounding Tips for Note-Taking
And then one of the ways , because it's hard to be able to write notes in the like time needed. And so one of the things that I found helpful is to, during the pre round, start writing those notes. Already write in the notes, what were the new labs. wright in if something happened overnight. So like any like pre charting, just go ahead and put them in the note that you're going to write for the day because one you're going to need it anyway. And two, it helps you when you're presenting. If you forget where it is, it's already on the note. So hopefully that helps.
Always finish your notes after rounds and before leaving for the day. This practice is crucial for maintaining professionalism and ensuring that all necessary information is documented in a timely manner. Pre-rounding by starting your notes early can be highly beneficial, allowing you to update information as you go.
Incorporate information from pre-rounding into your daily notes. This method helps you present during rounds efficiently and ensures that all important details are captured. Additionally, pre-charting saves you time and helps avoid last-minute rushes.
today we talked about a specific blog post, so I'll have that blog post linked so you can get more information. If you like these videos, subscribe to Life as a Patient Doctor anywhere you get your podcasts, including on YouTube. I also have other videos you can look at step one, If you're applying to residency, more about medical school, dealing with failure, with finances, imposter syndrome.
So I hope that those videos and blog posts help you. That's on medpsycmoss.Com if you want to get in contact with me, you can email me at medpsycmoss@gmail.com or you can follow me on all social medias @medpsycmoss Thank you for listening to my life, both as a patient and a doctor.