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[Clinical] My Completely Biased, Unsolicited, Hodgepodge Advice for Success in Medical School Clinical Years
Do fewer things of higher quality. Don’t fill your time and CV with BS activities. I like to do as little as much, but I do it to the very best of my ability. Find your passion and follow it to the best of your ability. Leave everything else behind, and don’t waste time doing things half-assed, or that you don’t care about, or just for the CV. Doing one or two things well that you are passionate about will pay off far more than doing a bunch of crappy activities that you are lukewarm about.
Prioritize recharging your wellness battery with hobbies, exercise, sleep, staying in touch with friends and family, and eating healthy. See a therapist early and often. Put your wellbeing #1.
Simplify your life. COVID-19 has actually helped me with this and showed me even more ways to simplify my life and offload mental burdens. Some ways to simplify your life: keep a to-do list, autopay, grocery delivery/curbside pickup, prescription delivery, have a few go-to meals that are good and easy that you make regularly, and eat leftovers and meal prep. My favorite cooking blogs are Cookie and Kate, Pinch of Yum, and Smitten Kitchen.
Always remember the big picture (if your relationship with your SO is falling apart, does it really matter if you get honors in that clerkship?). And if you’re not healthy now, then when? It’s only going to get busier as our career progresses, so prioritize your physical and mental wellbeing now, don’t wait.
Always live in alignment with your values (never sacrifice your integrity because the short term gain isn’t worth the long term insult to your character). Don’t lie because it’s damaging to your integrity, doesn’t help the team, and hurts your long term education.
Be curious. Don’t fear making mistakes, instead be curious about learning and improving. Let go off perfectionism, and instead focus on a growth mindset.
Be adaptable. Easier said than done, I know. The hardest part about M3 year is the constantly changing schedules, bosses, and expectations. So try your best to be flexible, and ask for expectations/feedback early and often. One attending will like a presentation one way, and the next will want it the exact opposite. This happens to everyone, so just let it roll off your back. Incorporate feedback, but don’t take it too personally, and just ignore and move on if not useful or constructive.
Use the Pomodoro technique to study. I like to use the app Focus Keeper, and I set it for 25 minutes studying with 5 minutes break. When I have a long continuous chunk of time, I repeat 25x5 for 3 hours, then I take a 1-1.5 hours break and do something else (usually workout and/or eat).
SUCCEEDING ON THE CLINICAL TEAM
The easiest way to get good clinical grades is to be interested, be friendly to everyone, stay organized, and have a thorough understanding of your patients. The expectations are lower than you think – you mostly need to be nice and put forth a good effort. Effort and kindness > fund of knowledge. Spend the extra time to connect with your patients because it makes the experience more fulfilling (and sometimes improves your grade because the attending may ask the patients’ opinions of you).
To do even better, you should find a way to make yourself valuable. There are a bunch of ways to make yourself valuable including: knowing your patients better than anyone else, offering to do tasks on residents’ to-do lists (such as calling outside hospitals for paperwork, updating patients’ on the plan, running by and checking on patients when nurses pages, etc), and being a positive, enjoyable teammate that people want around. Yes, you can also add value by bringing in home baked coffees once in awhile, but this should be genuine (ex for someone’s birthday), don’t get ridiculous with it or your co-M3s will start to resent you. The M3s who struggle make their attendings’ and residents’ lives more difficult and tiresome by being annoying, needy, rude, entitled, or getting in the way.
Demonstrate your interest by reading up on your patients and then find a way to mention your reading in discussions with residents/attendings. I would generally skim UpToDate or my clerkship resource on my patient’s condition, and drop a question related to my reading. It can also be worthwhile to review Journal Club (an app with landmark clinical trials) for your patient’s disease and mention a trial during your discussions.
Try to pick up simple, straightforward patients whenever possible. For example, the young person with DKA and no PMH will help you learn more about DKA than the advanced type 2 diabetic with DKA versus HHS, heart failure, COPD, etc. The picture gets too muddled.
Stay organized with Google Calendar, to-do lists, and Notes app or a small notebook for noting questions and feedback in the hospital. You can use OneNote or EverNote to keep track of notes on specific diseases and information like that.
ORAL PRESENTATIONS: In all presentations, it’s a good idea to “signpost” meaning say something to indicate organization (“Now I’ll move onto the imaging…”). If you’re on surgery or EM, keep it very brief (maybe only 5 sentences), mostly focused on A&P with relevant subjective/objective data tied in as evidence. For IM formal presentations, my H&P order is: HPI (focus on timeframe of onset, acuity, relevant demographic especially age, highly relevant PMH), pertinent ROS (pertinent only), PMH (with active meds and if the patients are compliant), allergies (especially antibiotics), family history (only immediate and only if relevant), social history (again, only if relevant – focus on smoking) then go on to objective data in order of vitals (if fever, include Tmax and if hypo or hypertensive, include trend of vitals with intervention), focused physical exam, labs (point out abnormalities, especially look for leukocytosis and bandemia), imaging, then one sentence summary and then assessment and plan. When talking with your team, use medical jargon, but use simple, clear terms with your patients and their families.
Organize your assessment and plan with a clear numbered problem list in order of importance. Put your nickel down and make a guess on your assessment and plan even if you’re wrong. One way to make sure you cover all problems is to include 1) chief complaint, then 2) objective abnormalities, then 3) chronic ongoing problems. A good way to generate a differential diagnosis is to include a life-threatening disease you don’t want to miss, the disease that is most likely and most common, and one disease zebra.
TESTS: When deciding whether to recommend a test, consider whether the result will change your management and if so, how. Recall that tests have different sensitivity and specificity and consider this when formulating a plan. After a test comes back, rearrange your problem list based on the posttest findings.
SOAP: SOAP is a shorter version focused on changes from the day before and stands for: subjective, objective, assessment, and plan. Make sure to note any interventions, changes, or acute events since the day before. Make sure to re-order problem list in A&P based on what is now the most important problem. For surgery, always ask patients about pain management, flatulence, and bowel movements since the day before.
POWERPOINT: For Powerpoint presentations, you can make them look extra stylish with pictures/design from Pixabay. Reference an article from Journal Club to look very academic.
OSCES: Highly recommend http://geekymedics.com to learn a great structure for approaching OSCEs.
APPS: Download Epic Haiku to your cell phone to look up labs on the go. MDCalc for common algorithms and those prediction models attendings like. I like Journal Club for landmark trials in each specialty. ACR Criteria is a good app for choosing which imaging to pursue. USPSTF is useful for preventive med guidelines, such as family med. I just downloaded this app, so barely used it yet, but CPSolvers has some cool schemas chief complaints.
RESOURCES FOR MULTIPLE CLERKSHIPS:
U World: This is so obvious that I almost forgot to write it – U World! For all clerkships, all the time. Hit those questions hard and make U World flashcards from the explanations to hit it again.
OME: Learn the basics of the clerkship by reviewing OME in the first week of the clerkship. https://onlinemeded.org I think OME is a little overrated in general, especially not great for advancing, but it’s fine for basics.
Emma Holliday: Emma Holliday Videos are invaluable when available (surgery, IM, psych, and peds). Watch the video, pausing to try to answer her questions, and reference her powerpoint slides for review.
Practice NBMEs: I used the NBMEs for every single shelf, and I found them indispensable. They are relatively predictive (perhaps a bit of an underestimate), and of course, the more questions, the better. They lack explanations, however.
Sometimes you’re just way too tired and burnt out to study. That’s fine. Instead, focus on a reasonable microhabit, like studying 20 minutes full-attention, and then quitting and relaxing. Don’t drag it out. Be efficient with full attention, and you can get a ton done in shorter amounts of time. And if things are becoming overwhelming, I go back to my earlier advice – ask for help early and often.
Internal Medicine: Oft repeated, but still true - my favorite resource was Step Up to Medicine. The most high yield topics to succeed in the clerkship are cardiology, pulmonology, and nephro (especially acid-base). I tried SketchyIM, but only found it okay. Although I loved SketchyMicro and SketchyPharm, I don’t think I’d recommend all that cost for SketchyIM as it was when I tried it at launch. Step Up to Medicine + 1400 U World questions is challenging to complete, but enough to rock the clerkship.
For more advanced/M4 learning, you can venture into some specific resources. I’m going to come down firmly and say I believe the best EKG book is The Only EKG Book You’ll Ever Need by Malcolm Thaler. I tried Dubin, and the formatting drove me crazy. You can read and understand Thaler relatively quickly, and you’ll have a great framework for EKGs. You can practice more EKGs with: https://litfl.com. I had a hell of a time understanding acid-base, and only recently really understood how to identify mixed acid-base disorders (besides eyeballing it). To really understand acid-base beyond primary disorders, I recommend the Acid-Base chapter in the The Ventilator Book by Williams Owens and a paper called A Practical Approach to Acid-Base Disorders by Richard Haber (1991).
Surgery: I highly recommend Surgery: A Case Based Clinical Review by Christian de Virgilio. I did not use this until after my clerkship, but I wish I had used it earlier. Surgery was one of my weaker subjects while studying for Step 2 CK, so I picked this up, and surgery became of my best subjects. This book rocks because it also includes a lot of medicine, which is a strong emphasis on the shelf and CK. Total Surgical Recall is okay for pimping in the OR, but not adequate for shelf studying. Pestana is commonly recommended, but I think too basic beyond the first week. General advice for surgery: practice suturing early at home with a kit (don’t wait for someone to teach you), and pretend you’re in the military when interacting with surgery faculty. As in, be exceedingly polite, respect the hierarchy, and always say “sir” and “ma’am.” I am not at all the surgery personality, but because of these guidelines for myself, I was surprised to find I got tons of positive feedback on surgery, even from the hardass stereotypical surgeons, and the clerkship director tried to convince me to switch to surgery. Yes, that was a brag, what can I say.
If you have trouble with feeling lightheaded during surgery, wear compression socks, slow your breathing with the 4 by 4 technique, don’t lock your knees in the OR, remember to drink water and eat regularly (avoid hypoglycemia), and look away from the surgical field if you need to.
Psych/Neuro: Neuro and Psych have a significant chunk of overlap, so it behooves you to understand both well. The better you know neuro, the better you’ll do on psych and vice versa. First Aid for Psychiatry is outstanding. For neuro, the neurology section in First Aid for USMLE Step 1 is actually super useful. I also used this while studying for Step 2 CK. I also liked Case Files Neurology, which I didn’t really hear people talking about, but I found useful. I tried Blueprints for Neurology, but didn’t find it to be in enough detail for my liking.
Peds: Highly recommend BRS Pediatrics. This is a big book, but outstanding. I think this is the only resource you need, so this section is easy.
Ob/Gyn: I never found the best resource for this one, but ended up using First Aid for Ob/Gyn most of all. There are Ob/Gyn questions on ACOG, but I found them repetitive and not particularly useful. Please comment if you found an awesome Ob/Gyn resource.
Family Medicine: Family Medicine is a combo of IM, Peds, and Ob/Gyn. Combine your resources for those clerkships, and you’ll be in better shape. Also focus on outpatient medicine and memorizing your vaccination and USPSTF guidelines.
EM: To do well in EM, you need to know how to workup an undifferentiated patient for each common complaint and what deadly conditions need to be ruled out. Don’t mess around with IM shit like hepatorenal syndrome blah blah. No, focus on chest pain, abdominal pain, stroke, GI bleeds, PE, ACS, sepsis, trauma, and that kind of thing. If you want to be clinically outstanding, practice your procedures and suturing thoroughly beforehand and be prepared to jump in hands-on. Look here for procedure guide videos: https://www.nejm.org/multimedia/medical-videos.
Radiology: You can check out https://www.med-ed.virginia.edu/courses/rad/or Learning Radiology: Recognizing the Basics by William Herring.
Anesthesia: Check out this handbook to get a lay of the land and basics: http://www.anesthesiology.uci.edu/downloads/advanced_clinical_rotation_605D_handbook.pdf
Dermatology: This Basic Dermatology Curriculum is awesome: https://www.aad.org/membeeducation/residents/bdc.
And I’ll stop there! There’s certainly room for more advice on M4, interviews, and all that, but I’ll save that for another day. I want to emphasize that I’ve gathered so much invaluable information and advice from multiple sources, so thank you to all the people that came before me. Hope this helps you, and good luck out there! Remember that the most important things are to prioritize your wellbeing and show up with integrity, a positive attitude, and strong work ethic. Don’t be too hard on yourself! If you disagree with any of my suggestions or have additional recommendations, please feel free to share in the comments.