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By The Class of 2016
By The Class of 2016
2
Class of 2016
MSIII Survival Guide
The beginning of third year can cause even the strongest of us to
become anxious since we neither know exactly what we are in for
nor what is expected of us.
Just a reminder, the rotations themselves are continuously
changing and evolving. As such, please bear in mind that this
guide is a best guess as to what you will see.
We hope it will be helpful to you!
Good Luck!!
How to use this guide:
If you read nothing else, read the first few sections as they provide
critical information about third year responsibilities. The specific
rotation sections are merely meant to be helpful tidbits, not a step-
by-step guide through the entire year.
A big thanks to all the MS2016ers who contributed to this guide!
We couldn’t have made it without y’all.
Andrew Usoro & Hillary Fitzgerald
Student Representatives, Class of 2016
Wake Forest School of Medicine
May 6, 2015
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TABLE OF CONTENTS
GENERAL RULES ........................................................ 5
MANUALS .................................................................... 10
PRE-ROUNDS .............................................................. 11
ROUNDS ....................................................................... 12
PROGRESS NOTES/SOAP NOTES ......................... 14
FAMILY MEDICINE .................................................. 17
INTERNAL MEDICINE ............................................. 19
NEUROLOGY .............................................................. 26
OB/GYN ........................................................................ 29
PEDIATRICS ............................................................... 34
PSYCHIATRY .............................................................. 37
EMERGENCY MEDICINE ........................................ 39
SURGERY .................................................................... 41
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GENERAL
MSIII
RULES
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Here are some tips that are useful on any rotation:
1) Be sure to know what is expected of you and what your responsibilities
are on day one of every rotation. The key is asking.
2) Always try to be accessible for the resident while not brown-nosing at
the same time.
3) Provide your beeper number to the resident and/or team on the first day
of the rotation. Most services have a list with important numbers on
the bottom (resident beeper numbers, numbers for the lab, etc.). If not
on a “list,” get your residents’ beeper numbers on the first day so you
can reach them.
4) The residents are the people responsible for most of your clinical
evaluations/grades. Make sure you portray a proper attitude despite
being tired or overworked. Your evaluations will show it.
5) Never, ever correct your resident on rounds. Wait until after rounds to
discuss matters, unless of course a patient’s life is at stake.
6) Don’t leave early unless you have permission and don’t ask to leave
early. However, when told to go home, don’t be told twice.
7) Avoid discussing patients in elevators, cafeterias and other public areas
when there are other people around.
8) Don’t badmouth other students, interns, nurses and staff around others;
word gets around. Interns/residents will sometimes badmouth their
peers and complain. While tempting to join in to “fit in”, don’t.
Resisting this temptation will save you from making the comment one
day that will get you in real trouble.
9) Share the workload with your fellow classmates. Try to balance out
weekend calls, picking up patients and other responsibilities. It all
seems to balance out in the end, and no one likes the student who is
constantly trying to get out of their duties.
10) Most of the time, you’ll be on service with at least one other student.
You can hang together or hang separately. Students can make other
students look bad by a) correcting other students on rounds, and b)
asking questions of students designed to make them look stupid. This
will earn the enmity of your classmates and a bad evaluation from the
interns/residents. The best grades are given to student teams who work
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hard and well together, who don’t complain and who ask for “more” to
do for their residents.
11) The shelf exam affects your grade on each rotation, though to a
different extent on each one. Study! It is best to stay on some kind of
schedule, as time to cram may disappear as your service gets
unexpectedly busy. Try to read a little bit each day about patients you
have but also remember that the test may cover topics you didn’t see on
the clinical part of the rotation.
12) Call varies on each service. Some services assign call dates. Some
require you to make your own schedule. If you are engaged in patient
care activities at that time, you are expected to finish these before going
home.
13) OB, Trauma Surgery & Peds require in-house call (staying overnight in
the hospital) for a few nights in a row. Try and get yourself on schedule
before your first night by staying up as late as you can on the night
prior to your first overnight call.
14) On some services, if you are on call on Friday, you have to come in to
present the new patients on Saturday. Likewise, if you are on call on
Saturday, you have to come in to present the new patients on Sunday.
This is entirely rotation dependent. Some services just want to have
any medical student there for each weekend day for rounds only.
15) Your appearance says a lot about you. You should know how to dress
professionally at this point in your life.
16) Weekends are generally dress-down. Hardly anyone wears a tie, and
some attendings actually wear jeans. This does not mean, however,
that you can come in sporting denim. On Internal Medicine, scrubs are
allowed on the weekends. Just ask your residents what weekend attire
should be.
17) WRINKLE-FREE will make your life much easier.
18) Don’t take it personally when the patient gives a totally different story
to the attending than he/she gives to you. This happens to the residents
as well. Also, don’t feel bad if the labs you just checked on suddenly
come back during your presentation.
19) On each service, find out what the team would like to have presented
on rounds. Surgery rounds are far different from medicine rounds.
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“Pertinent positives from the review of systems, labs and physical
exam are…” should be your mantra.
20) Who’s Who in the hospital (by badge colors):
Red - Pastoral Care
Gold - Faculty, Administration, Residents
Green - Students
By scrub colors: light blue—physical therapy; gray—respiratory
therapy
21) Nurses can be your best friends or your worst enemies. Don’t get them
angry, and don’t make fun of them
22) Almost all residents and most fellows will prefer you to call them by
their first name. But it’s safe to call them “Doctor” until corrected.
23) Eat breakfast in the morning... you might not get lunch. This is
especially true on surgery. Also, it’s not a bad idea to carry snacks in
your jacket pocket—granola bars, crackers, etc.
24) Don’t worry about bringing an ophthalmoscope/otoscope; most floors
have one available, just ask the nurses.
25) Never leave the hospital in green scrubs as the hospital gets fined for
such infractions (and you will get yelled at!).
26) On numerous rotations you will have to go to the Downtown Health
Plaza of Baptist Hospital or DHP (Peds, OB, Surgery, and Medicine).
Here are directions: I-40 Business East to US 52N, then take Martin
Luther King Jr. Blvd. exit. Take a left after the exit ramp ends onto
MLK. DHP will be on the left.
27) There is a “chain of command” on the wards. Interns report to residents
who report to attendings. Some services (like some surgical services)
take this more seriously and paging or discussing something with an
upper-level resident before you call your intern will get you at least a
polite reprimand. When in doubt, call/ask your intern first. You can’t
get a better grade by always running to the upper level/attending, but
you can get a worse one.
This is a functional system. Interns have 6 – 13 patients, upper level
residents have 25 to (on call) as many as 100, attendings have all the
inpatients on their service, plus clinic, plus research. If the latter had to
answer every question about “Mrs. X’s sodium is elevated”, they’d
never see their families.
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Trust us, if you make your interns look good (by handling problems
together with them, asking their advice, asking them to teach you),
word will get to the upper levels and attending and you will get the best
evaluation possible. Really.
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MANUALS
There are several pocket manuals available which can be helpful on the wards. If
you are unsure of which one would be most helpful to you, you may want to ask
a fourth year or intern if you could borrow one for a day or so and give it a trial
run.
Books:
Pocket Pharmacopoeia
A tiny 5" x 3" book available at the bookstore and from many pharmaceutical
reps. It contains prescribing information about medications sorted by disease
process.
Maxwell Quick Medical Reference
This multicolored guide contains invaluable day-to-day instructions for writing
progress notes, H & Ps, and orders. It also has a handy neurology review,
OB/GYN section, and mini-mental status exam. And it fits nicely in the chest
pocket of your white coat.
Sanford Guide to Antimicrobial Therapy
You can often get this little book from a drug rep if you are lucky, especially on
the family medicine rotation; otherwise it’s available in the bookstore. It is
helpful for quick references as to which antibiotic to use for which condition.
Pocket Medicine (“Little Purple Book”)
Most helpful on your inpatient medicine and surgery rotations as a quick
resource for disease epidemiology, etiology, diagnosis, and treatment.
Washington Manual
This book is treatment oriented and gives you a very brief synopsis of most
major diseases along with details of the appropriate therapeutic plan. Probably
more helpful for AI’s or intern year, but some thought it was great.
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PRE-ROUNDS
“What are pre-rounds?” Basically, pre-rounds consist of you coming in before
morning rounds to find out what went on the night before with your assigned
patients. These are just general tips. However, the best way to know is to ask the
first day of a rotation what data is expected to be collected.
How to pre-round (this varies with the rotation):
1. Allow yourself at least fifteen minutes per patient for pre-rounds (more
for the first couple of days, until you get the hang of it). Again, it is
best to ask what is expected of you on the first day.
2. Look up the patients’ charts on EPIC and look to see if any additional
notes have been written since you left the day before (consult notes,
resident on-call notes, PT/OT/ST, etc.) and read through them on EPIC.
3. Check EPIC and see if there have been any orders put in that you don’t
know about (labs, x-rays, med changes).
4. Check the computer to see if there are any labs back, even if you think
there aren’t (always check cultures from the day or two before!). If
labs are abnormal, make sure you look at past labs to see the trend.
5. You can keep up with the meds that have been given by reviewing the
the Meds History section on EPIC. This is the best way to see what
meds the patient actually received the day before. Note which day of
antibiotics your patient is on. (e.g., Cipro, Day 6 of 7).
6. If there are any radiological studies pending, but no report, always try
and read them yourself! Give your opinion if there is no report. Ask
your resident where you can find a computer with the iSite system to
look at radiology films.
7. Always always check vitals for every patient on EPIC. Check your
standard vitals, but it’s also important to know daily fluid input/output,
fluid from drains, blood sugar levels, pulse ox readings (i.e., O2 sats).
Know the ranges of vitals throughout the day (i.e. max and min BP)
8. Go see the patient. Don’t feel bad about waking them up. Say, “Good
morning,” “Sorry to wake you,” etc., then proceed to ask them how
they are doing.
Ask how they did overnight.
Do a focused physical exam [heart, lungs, abdomen, and other sites
relevant to their condition and procedures (incision, reflexes, etc.)].
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ROUNDS
Though rounds vary vastly from service to service, the basic model fits almost
all rotations. Some last hours while others are considerably shorter. Outpatient
rotations don’t have any at all. To cut down on your anxiety, remember three
simple principles:
1) Be as brief as possible with your presentations. If you address the
appropriate areas of history, exam, and labs, but you do not describe
something someone wanted to know, they will probably ask you.
2) Remember you are describing history, exam, and labs, but the true
point is to demonstrate that you were analyzing the data and turning
them into useful information, which you demonstrate in the Assessment
and Plan part of the SOAP note (see following section). If the
electrolytes are abnormal, you should mention why they are abnormal
in your assessment and plan, how you will correct them, or if they are
abnormal but stable.
3) Organization ahead of time will always help. Shooting from the hip on
rounds (often when sleep deprived) has a way of making you forget
things and appearing (and being) disorganized.
On inpatient rotations you will usually present your patients. There are two
basic formats: new and old patients.
New Patients:
1. As time permits, organize what you are going to say on rounds when
you get a new patient. Organize your summary sentence about a
patient’s history and presentation when you first get a new patient
(“67yo WF w/history of SLE admitted for rule out MI.”) It’s boring to
have anyone just read a written H&P, but do not feel that you need to
have it memorized. Consider photocopying your H&P (on the nursing
station Fax/Copiers) and then highlighting the important points for your
notes.
2. Unless the team indicates that they want the short version (as on most
surgery services) on the initial presentation day, don’t give the
summary, but give a full, relevant history. Remember, you are leading
the team along with your clinical thinking as to why you have ordered
or planned what you have for this patient’s condition.
3. Always know the past medical history, past surgical history,
medications & dosages, although reporting the dosing details depends
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on rounding team style. Carrying a copy of the H&P in your pocket
allows you to have this info at hand.
4. Deep psychosocial histories are seldom appreciated (even if they
should be). Summarizing a stressful home life would be enough if it
were important - this is NOT TRUE on psychiatry.
5. DO NOT describe every detail of your physical examination. This is
BORING to all involved (just listen to one of your colleagues do
this), and one of the beginning MSIII’s most common mistakes on
rounds. Instead, just try to include all exam findings, both positive and
negative, related to the patient’s condition. If you are not sure of an
exam finding, stating your confusion (“not sure if I heard a murmur”)
may be a good way to get some bedside teaching. If your attending
makes you nervous, ask your residents later. Do not pretend that you
heard or saw something that you did not see or hear.
6. Try to have an assessment and plan, or at least an understanding of the
one that the intern (and maybe more than one resident) has written
down ahead of you. Again, show your thought process.
Old Patients:
On follow-up days for the given patient, start with your summary
sentence to remind the team who the patient is. Give any overnight
changes, physical exam findings that have changed or are being
monitored, labs and other studies, and be prepared with the plan for the
day (new issues, discharge, upcoming procedures, and med changes).
CHECK-OUT ROUNDS
Check-out rounds occur at the end of the day when the team regroups and makes
sure that the plans for the patients were completed and, if not, to tie up any loose
ends. In order to do that, you need to know what has happened during the day.
At some point during the day, stop by your patients’ rooms to find out how they
are doing. Check-out rounds are not as formal as morning rounds. Just give a
quick synopsis of major occurrences, planned and unplanned.
Nothing looks worse that saying you do not know how your patient has been
doing throughout the day. Make sure that you stop by and see your patient
sometime during the day, even if they are very stable.
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PROGRESS NOTES EXAMPLE
Most inpatient rotations will require you to write medical student progress notes
on EPIC. Ask your residents for a good template to use to make it easier. Here’s
how it’s done:
SOAP = Subjective, Objective, Assessment, Plan
S: What the patient tells you they feel like (similar to history portion of
H&P). This will generally be very short unless you are on psych. This
also includes any tests or scans that were done, but don’t give the
results, that comes in the next section. If the patient is unable to talk,
you may use info from parents, nurses, etc. (just make sure that you
mention that it is “per the mother, RN, etc.”)
O: Vitals for last 24 hours (typically in this order): Tmax, BP, HR, RR,
O2 sat and on what form of O2 (room air, 2L nasal cannula, face shield,
etc.). Include the Ins and Outs (usually in milliliters or cc’s per 24
hours). Often you need to record # of stools. The “Vitals” tab of EPIC
provides a nice summary of the past 24 hours in 4-hour increments.
Physical Exam (at a minimum lungs, CV, abdomen):
General: 64 yo bf, alert, cooperative, in NAD (no acute distress)
Heart: Reg rate and rhythm without murmurs, rubs, gallops (RRR
without M/R/G)
Lungs: Clear to auscultation bilaterally (CTAB)
Abdomen: Soft, nontender/non-distended, positive bowel sounds,
without hepatosplenomegaly (S, NT/ND, +BS, no HSM)
Etc.
Labs: [refer to your Maxwell guide for shorthand notations]
CBC, CMP/BMP, any other daily labs
Follow up on cultures from previous days
ABG: pH/pCO2/pO2/HCO3/O2 sat-FiO2
Radiology reports: CXR, MRI, etc.
A/P: Assessment and Plan
Can combine these two
Classify and enumerate your plans based on body systems or patient
problem list.
Start by repeating summary of patient with hospital day #, post-op
day # if applicable, and day # of any antibiotics or other treatment
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regimens. On surgery rotations, it is a good idea to put the post-op
and antibiotic day numbers at the very top of your note.
Example: A/P: 42yo BM s/p MVA w/ Fx R. Femur, HD #5, Unasyn
day #2
1. Resp - continue current vent settings
2. ID (Infectious Disease) continue Unasyn 3 gm IV q 6o
and follow temps
3. CV - still hypertensive - increase Lotensin to 20 mg/day
4. Disposition - social work looking for nursing home
placement
The plan is the most difficult thing to learn during the third year. Actually, you
will be working on this section for the rest of your life.
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MS3
ROTATION
GUIDE
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FAMILY MEDICINE
Course Director: Dr. Scott Harper
This 4-week rotation is completed at Piedmont Plaza, which is just up the hill
from CompRehab and past Whole Foods. This rotation primarily consists of ½
days of clinic and ½ days of lecture (usually only a couple of lectures per day).
A few of these ½ days are in a community clinic, with one shift at the
Community Care Center (where DEAC is held) and an assigned shift to med
team at DEAC.
You are evaluated after each of your clinic sessions, using a hard copy form
available in the workrooms. Have a form in your pocket, ready to go at the end
of your session. Often, you’ll get your feedback right then and there, which
helps you know what to work on your next time in clinic. If things are busy, they
might do the form later—don’t worry, that doesn’t mean you are going to get a
bad eval!
Other rotation assignments include two videotaped patient interviews and
physicals, which are reviewed in realtime by your preceptor. (You are paired
with another student, who can chime in and help move things along when it is
not their turn to be the main interviewer.) You will also have a couple brief,
informal group Power Point presentations on Family Medicine relevant topics,
two SPA-like standardized patient interviews and physicals referred to as
“FOPAs,” which are videotaped and reviewed with you by a Family Med
faculty member. This is a fun, low-stress rotation with good hours and
attendings who are very happy to have students.
Helpful Hints:
1) Family Medicine Tutorials, or FMT’s, are lectures/discussion sessions
led by attendings and residents. Make sure to read the relevant text
before the session: sometimes you’ll be pimped and assessed based on
your level of participation.
2) Even though the blinking red light in the in-room video camera is
unnerving, don’t get nervous during your videotaped interview and
physical - the review process is informal and also a learning
experience.
3) When presenting a patient in clinic, be detailed but focused, proceed in
a logical order, and always present an assessment and suggest a
plan. Being wrong is better than saying nothing as long as you try.
Texts: 1) There is no assigned textbook. Dr. Clinch will suggest some electronic
textbooks for you to prepare for the national shelf exam.
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2) Other resources you normally use to look up things, i.e., Harrison’s,
Cecil’s, UptoDate, etc.
3) FYI, each central room of the clinics is supplied with several books that
you can use to look things up (i.e., Harrison’s, PDR, Goodman &
Gillman, anatomy books, etc.).
Things to do: 1) Attend the morning sessions and lunch conferences on Tues.,Thurs.,
and Fri. The topics can be helpful for the shelf or just plain cool
(health clearance for participation in extreme sports), and you are fed
lunch—who doesn’t like free lunch?
2) Email your preceptor the day before to ask if you can look up the
patients to prepare for that clinic session. (Some patients could be
faculty or students who are familiar to you, so you would be told not to
look at their charts for privacy’s sake.) It’s good to have a general idea
what the patient is being seen for before walking in the room.
3) If you have a concern about a clinic evaluation, talk with the evaluator
immediately.
4) For course evaluations, provide useful comments; the department is
very attentive to areas of improvement and will make the appropriate
changes.
5) Assist with procedures when possible. There are also several regularly
scheduled procedure clinics you can attend if you are interested—just
ask.
6) Review bugs and drugs. Brush up on your MSK exam. Know
indications for different health maintenance checks, e.g.,
mammograms.
7) Track ALL of your patients in Patient Tracking on eWake daily. Get
credit for all that you’ve seen!
Things not to do:
1) Assume that Family docs refer out most of the cases - not true. They
refer out only 5% of cases.
2) Be late to clinic. Make the most of your limited clinic sessions!
3) Take the last of the coffee in the breakroom without starting a new pot.
Grades:
1) Clinic performance and evaluations.
2) Shelf exam. There is a reason this rotation allows more time to study
than others—the shelf is notoriously hard. Family Medicine is
comprehensive care, which means the content you can be tested on is
equally broad. Study incrementally.
MS2016 Contributor: Hillary Fitzgerald
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INTERNAL MEDICINE
Course Director: Dr. Cynthia Burns
The clerkship is 12 weeks long, with a month on a general medicine service, 2
weeks on cardiology, and 2 weeks on either nephrology, hem/onc, or leukemia,
and a “transitional medicine month,” which is mostly outpatient care. You will
take call/work on weekends while on the inpatient services, but there is no call
or weekends on the ambulatory component.
Along with surgery, inpatient medicine is one of the “big 2” rotations in third
year. These are the grades that residency directors pay special attention to,
regardless of what specialty you go into (remember, many will require you to do
a transition year in internal medicine first). And of the two, gen med may be the
more important. “A good letter from your medicine rotation will always impress
a surgery program, but a good letter from surgery may not mean as much if you
apply to medicine,” says a surgery residency director who will remain nameless.
So, get up for the game, be early (before your interns always is impressive) or at
least on time, stay late (but not after they tell you to go home), know your
patients better than anyone, form good relationships with the nurses and other
members of the care team, dress nicely and strive to learn and improve your
presentations as you progress through what can be a quite long rotation.
Medicine is all about forming a good assessment and plan, which includes
having a good differential. For instance, if you have an abnormality on one of
your patient’s labs or vitals, in your plan, you should address this; e.g., “Fever:
wound infection vs. other GI etiology vs. pneumonia. Recent history of wound
instrumentation favors wound infection. Start on Unasyn for broad gram
positive/negative/anaerobic coverage. Obtain blood, urine, and wound cultures.
Obtain CXR to r/o pneumonia.” On the SOAP note in Medicine, you will spend
the most time by far on the plan. Make sure all problems are accounted for,
including patient complaints, PE findings, and lab abnormalities. You can lump
things together when possible (ie: Fever, cough, CXR consistent with
pneumonia as just pneumonia).
Medicine is also the time to work on your presentation skills. While it will vary
some from attending to attending, they generally stick to the standard H&P
format for new patients and SOAP note format for updates. Ask your attending
on the first day what they want (ie: just pertinent positives, all lab values, just
abnormal labs, etc.). You will pick this up from the residents as well. Work
towards giving your presentations in such a way that you tell the patient’s story
and your audience can’t help but come to the same conclusion you did, rather
than finishing and the first question being, “So why are they here?” Most
attendings on the general medicine services, as well as the acute care for elderly
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(ACE) unit attendings, will request bedside presentations. These can initially be
quite challenging, so be sure and ask your attending and residents for some tips
before your first one. Dr. Burns also has some great advice about this, so ask her
at orientation so you show up prepared from day one.
You will also have to read voraciously for medicine. Most people do a little
reading daily, either on their patient’s issues or on the general topic. A lot of
people use Step Up to Medicine. It is systems-based, outline format, but with
more words and complete sentences than First Aid. It’s a good mix of breadth
and depth. However, it is long (~500 pages), and there are other sources that are
helpful for shelf-studying. While reading Harrison’s sounds like a noble idea,
you should probably stick to a review book, and doing some practice questions.
The main point here is to find a book or combination of books and internet
sources to provide the information you need without being overwhelming; this
will depend mainly on your own style of learning.
N.B.: While doing well on the Shelf is obviously an important part of your
grade, don’t neglect reading up on your patient’s specific problems and
conditions each night. Just 10-15 min spent on hyponatremia will make you look
like a rockstar the next day on rounds and help you be prepared for questions
you are likely to be asked.
Check in with your upper-level resident after the first week. Ask how he/she
feels you are doing, how are your presentations, what could you do to improve.
If you show improvement, your evaluations will focus on that. Also, you have to
meet with an attending during the 6th week, and fixing some of your weaknesses
before HE/SHE tells you to shows insight and initiative.
Remember that a good letter of recommendation from your medicine attending
can really bolster a residency application. Even if you have this rotation first and
don’t expect to do medicine, if you do a good job, ask for a letter before or just
after you leave. It’s great to have in reserve and will, as we said earlier, help
toward virtually any residency you apply for. However, don’t stress about
getting letters in 3rd
year necessarily. You will have many more chances in 4th
year to get letters. But putting your name/face on a particular attending’s radar
can help facilitate that process early on during the 4th
year.
INTERNAL MEDICINE: INPATIENT
For inpatient medicine, you will typically spend 4 weeks on a general medicine
service (Gen Med A, B, C, or D), two weeks on a cardiology service (Cards
Gold or Cards Blue), and 2 weeks on either Leukemia, Hem/Onc, Renal. You
will also do one week on the ACE Unit (an inpatient service) during your
transitional medicine month.
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Helpful Hints: 1) Be enthusiastic. Be a team player. Be respectful of your peers—
sometimes there can be 3 med students on a team (usually 2), which
can feel excessive. Allocate new and interesting patients fairly.
Residents and attendings notice.
2) Rounds usually start around 8:30 am on Gen Med services and most
specialties. On cardiology,, they begin at 7:30. You, however, will
arrive at 6 am at the latest with your interns to get morning checkout.
This will also give you plenty of time to pre-round and start your notes.
It’s best to contact the students who were on the rotation before you, or
check with the upper level resident for details. During rounds, stay
engaged and interested. Sometimes the teams can be quite large, but
don’t get lost in the shuffle. Keep a “to-do” list for each patient (not
just yours!)—this will help you stay engaged and knowledgeable about
patient care plans. Also, don’t be afraid to speak up if an intern starts
presenting your patient. They can’t always keep up with who is
following who and won’t mind at all if you take ownership of your
patient. You worked hard pre-rounding—don’t let that go to waste!
3) Dr. Burns allows students to schedule their own call schedules. During
inpatient months, one student from each team will need to be present.
You can discuss with your co-student (s) if you prefer gold or dark
weekends or a combination. Weekend responsibilities include pre-
rounding/getting vitals, rounding, writing orders (the resident will have
to cosign the orders, but it’s good practice if the resident is ok with you
doing this), completing discharge documents, and tying up loose ends.
On weekends, there is usually one intern, the upper level, one student,
and the attending rounding. This is a great time to get some one-on-one
time with the attending, so don’t slack on the weekends! Also be sure
and help the intern as much as you can with any tasks after rounds.
4) You will have one week of nights while on your general inpatient
month. This is a great time to participate in admissions. Also, use this
time to talk to the intern about any questions you have (as long as
he/she isn’t too busy!). There can be quite a bit of downtime at night,
so also get some studying done.
5) You get to do procedures, but you will have to be assertive. The
interns are always offered the procedures first, but they may let you do
it if they’ve done enough and you are interested. Always ask and show
enthusiasm. However, don’t do procedures during the day on another
student’s patient. That is very bad form and sets up poor working
relationships.
6) Don’t ignore the specialties that you may not get exposed to or do not
have as a rotation (i.e. renal, pulmonary, GI). They are on the exam!
Texts:
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Pocket Guides: Great for looking up quick facts on rounds or formulating a
plan. Pick 1 of the first 4. Everyone has a Maxwell’s and many get the Sanford
guide too.
1) Pocket Medicine: Very popular with residents and students alike. Try
and look over the whole book during the rotation. A great reference for
most things you will encounter on the wards.
2) The Washington Manual of Medical Therapeutics
3) Harrison’s Principles of Internal Medicine: Companion Handbook
4) Ferri’s Clinical Advisor
5) Maxwell: Quick medical reference. Has normal lab values, ACLS,
what to put on various notes
6) Sanford Guide to Antimicrobial Therapy - all the bugs and drugs info
you ever needed
Practice Questions: Practice makes perfect.
1) MKSAP questions - Available for free through the library website. Dr.
Burns will give you details regarding logging in. Great for Shelf and
wards prep.
2) UWORLD—There are quite a few internal medicine questions, but try
and get through them all over the course of the rotation. Start early, and
try and get a lot done during your transitional medicine month.
Review Books: Pick one and stick to it.
1) Step Up to Medicine: Outline format but more thorough than First Aid.
2) Medicine Blueprints.
3) NMS Medicine: a good study guide for the rotation, but long and
dense. (400 pages); A good text to prepare you for rounds & the neuro
section can help you for your neuro rotation.
4) First Aid for Medicine: more concise than NMS, but also not as
thorough. Make sure you have an up-to-date copy.
5) For Cards/CCU: Dubin’s EKG can be helpful. Some prefer Thaler’s
The Only EKG Book You’ll Ever Need.
Textbooks: Not as helpful.
1) Harrison’s Internal Medicine - good if you need to go all the way back
to basics, but far too in depth for studying
2) Cecil’s Essentials - A little lighter than Harrison’s, but still probably
too heavy as your primary source
Things to do: 1) Become familiar with PFTs, electrolytes, ABGs, common EKG
patterns, and acid-base problems.
2) Study when you have time and things are slow.
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3) Know your patient’s medications. Make sure you look to see if the
patient actually received a medication. A med may be ordered but may
not have been given for some reason. Check Epic!
4) Have a plan, even if they change it.
5) For cardiology, it’s helpful to review EKG’s, CV drugs,
Pathophysiology, and CHF & CAD risk factors.
6) Attend all student afternoon case conferences. Also, look for especially
interesting patients to present for your case conference.
7) Help out with patients who you aren’t following when you can; the
interns are often overwhelmed and any help will be appreciated and
noticed. Just don’t do this for another student’s patients unless it’s the
weekend/night or you have checked with the other student first!
8) Each day during rounds, try and keep a “scut list” going with tasks for
each patient for the day. This is what the interns do, so it will be good
practice for you and will help you stay engaged in rounds.
Things not to do: 1) Sleep through rounds. (It is easier than you might think)
2) Whine about being on call.
3) Take all the interesting patients each morning—share!
Attendings/House Staff: 1) Most attendings like to teach. Take this opportunity to learn and get to
know them personally.
2) House staff are friendly and also like to teach. Don’t be afraid to ask
about the plans for the patient, the diagnosis, hints on presentations, etc.
It can be helpful to touch base with your intern just before rounds to
make sure your plan makes sense and that they don’t know something
you don’t.
3) Always ask for feedback on how you’re doing! Not only does this give
you helpful hints for perfecting your skills, it lets the attending/house
staff know you care about how you’re doing!
Grades: 1) Balance your efforts between hard work on the wards (organization,
background reading, clinical learning and scut) and preparing for the
final.
2) The shelf exam is a large portion of your grade and very tough: 100
questions—and time is a factor on the exam. There are certain Shelf
scores required for honors/high pass/pass, so if you are a true rockstar
on the floor but do only mediocre on the exam, you will not get honors.
Regardless of what people say, study!!! But realize that doing well on
the floor is (by the numbers) more important. 75% is from written
evaluation by all of the interns, residents, fellows and attendings with
whom you have worked. This is where staying late on-call nights,
being prepared on rounds, and doing SCUT work comes in. Knowing
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your patient and being prepared and organized is the most important
thing. Never try to pass off being tired as an excuse for sloppiness.
The residents get a lot less sleep.
Medicine Services: All services deal with general internal medicine problems that lead to
hospitalization. Renal is “Gen Med with renal failure”; Hem/Onc is “Gen Med
with solid tumors” – so you will see plenty of general medicine on every
service.
Gen Med A-D: There are patients with DKA, PE, pneumonia, cellulitis, r/o MI, nursing home
placement, HIV, TB, and GI problems. The teaching is generally very good but
is attending- and resident-dependent. Rounds are long; Gen Med D is the
Chief’s Service, which means one of the Chief Residents is your attending.
ACE Unit: ACE is Acute Care of the Elderly, located in the Sticht Center. Key items to
address and document on every patient include a mini-mental status exam, GDS
(Geriatric Depression Scale), ethical issues (DNR/ power of attorney), and
Disposition. Physical exam is especially important on this service as patients
who are demented cannot communicate with you about how they feel. During
your week on the ACE unit, you will also have experiences at skilled nursing
facilities, home visits, and geriatric clinics. These attendings are some of the
best in the hospital—you will learn so much about physical exam maneuvers
and elderly-specific care from them. They are great teachers and will often take
the students around in the afternoon for teaching rounds. There are no interns on
this unit but sometimes 4th
year acting interns, so you can pick up a few more
responsibilities. Bedside presentations will be expected.
Cards Gold/Blue: This is a very busy rotation for the third year student; you can learn a lot and get
in a few procedures. Both Cards Gold and Blue have patients in the CCU.
Rounds start at 7:30 and are typically pretty fast paced. Work on giving focused
presentations, but always ask you attending about presentation expectations.
Always grab your patient’s latest EKG before rounding. Be prepared to read
EKG essentials (rate/rhythm/axis/etc.) on Day 1. Also, have already brushed up
on standard treatments for STEMI, NSTEMI, CHF, etc. You will have rapid
turnover of patients and the rounds and hours are long. Hang around and you
will get to see and do more. Try to see a cardiac cath in the cath lab, if possible
– just ask the fellow on your team. This is a stressful rotation for the residents,
so realize that they may often seem tired and a bit stressed. They are usually still
willing to teach at the appropriate time, so just gauge when a good time would
be to ask about your patients. The fellow can also be a great source of teaching
and knowledge—use him or her! Be prepared to perform CPR on codes.
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Renal: Generally has long rounds but the attendings are all great. You usually attend a
mini-lecture in the mornings, which is designed for the residents; these lectures
cover topics like calcium regulation and looking at urine specimens - great for
review. Review renal diseases, renal failure, electrolyte disturbances, and Dr.
Freedman’s “Rules of 7s” before you begin.
Leukemia: On this service, there is minimal patient turnover. It is not uncommon to have
many of the same patients by the end of the rotation. There are a fair amount of
vas caths that have to be placed, so if you are assertive, they may let you try one.
The patients are usually very nice, but very sick, and can crash in an instant.
Review AML and neutropenic fever as this is the majority of what you will be
dealing with. Didactic lectures are given several times per week, and the team
goes on Bone Marrow rounds daily to examine bone marrow specimens.
Heme/Onc A: Notoriously one of the hardest rotations for residents, which means lots of work
for you too. Hours depend on patient load, although they tend to be a little
longer. These patient come in with general medicine issues (and happen to have
cancer) or for their cancer/hematologic problems. You’ll see a lot of sickle cell,
and solid tumors. The patients tend to be sicker and many are sent to hospice.
Be sure to know their oncologic history, like prior chemo regimens and why
stopped. Didactic lectures are given on this service several times per week
which offers good opportunities for learning from attendings and residents.
TRANSITIONAL CARE EXPERIENCE
This 4 week component is comprised of one week of Procedural Experiences
(phlebotomy, respiratory therapy, physical therapy, occupational therapy, GI
endoscopy, hemodialysis), one week at Hospice, and one week in Outpatient
Medicine clinics (DHP or ODP), as well as an inpatient week on the ACE unit
Helpful Hints: -You will have more free time during transitional care month, so try to use it to
study!
-You will have a card during your clinic week that will need to be filled out by
an attending saying they watched you give presentations, do exams, etc. Get
started on this card from day 1 of clinic so that you have plenty of chances to get
it done.
MS2016 Contributor: Eli Crowder
26
NEUROLOGY
Course Director: Dr. Maria Sam
Overview:
The assigned services for the Neurology clerkship include the following: 1 week
on the Stroke service, 1 week on the General Neurology service, and 2 weeks on
the Neurology Outpatient Clinic. Typically, the schedule alternates between
inpatient and outpatient weeks. On the Stroke and General Neurology services,
students cover as many of the patients as possible, with a maximum load of 4
patients per student. There are usually 3-4 students on each of these services at a
time. In general, rounding begins around 8:00 a.m.; students typically arrive at
6:00 a.m. unless instructed otherwise by the upper level resident to pre-round on
patients. During the two weeks of outpatient clinic, students are assigned to
attendings in different subspecialties in order to gain exposure to a broad range
of neurological topics and conditions. Students typically work in both morning
and afternoon clinics each day of the week. The level of involvement
(shadowing vs. interviewing) depends on the particular attending’s preferences.
Inpatient clinic:
The most important concept to be comfortable with going into rotation is
"localization." They'll drive it home through the lectures and your time on
Stroke Service, but if you want to study anything early in the rotation or to
review the night before you show up, it's that. Basically: Is the problem cerebral
(where), subcortical, brainstem (where), spine, peripheral nerves, neuromuscular
junction, or muscles? You should be able to figure this out by the laterality and
pattern of symptoms, as well as the disease course. For stroke, you'll do great if
you are familiar with the various Circle of Willis syndromes (lateral medullary,
pontine/basillar, AICA, etc)...
When giving presentations, treat it sort of like a comprehensive medicine SOAP
or HPI, but really focus on the neuro components -- basically the neuro history,
stroke risk stratification (lipids, echo, carotids, A1C, etc), and the neuro exam
(particularly interval change on neuro exam). Be comprehensive -- actually do
pronator drift, all strength and reflex components, all CNs and a comprehensive
visual exam (if relevant). You'll also impress the residents/attendings by doing
MOCAs on your patients, and those are fun -- so do it.
Outpatient clinic:
In outpatient clinic, you'll never be rushed with patients, so take your time
talking to them and doing exams. There are no other clinics in 3rd year (other
than psych) where you have such lengthy 90 min appointments. Enjoy it.
Lectures:
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Lectures on this rotation are useful but are not sufficient for success on the
rotation and shelf exam. However, studying these alone is sufficient for the
quizzes, which are conducted at the end of each of the first three weeks of the
rotation (for a total of 3 quizzes). For the shelf exam, use of additional study
materials such as Case Files, UWorld, Blueprints, etc. is recommended in order
to cover the big themes and major diseases in Neurology.
Quizzes:
Weekly quizzes are garnered from the previous week’s lectures. Quizzes are
composed of 10 multiple choice questions (10 points each) and 1 essay question
(100 points). The score equals the average of the multiple choice and essay
portions of the quiz. The three quizzes will be reviewed during a session with
Dr. Sam during the last week of the rotation. One quiz grade can be replaced by
the Bedside Exam grade (generally helpful for your overall grade).
Bedside Exam:
The Bedside Exam involves performing certain portions of the neuro exam for
grading by an attending (cannot be a resident). It is worth 100 points total.
Students are able to choose the patient, so choosing a familiar patient is
advantageous. It is recommended to complete the Bedside Exam during the
second half of the rotation once students have gained more experience with the
neuro exam.
Call:
All students must take either one weekday night or one weekend day of call on
the Consult service. The specific date that each student wants to complete this is
up to them. If a student chooses night call, then he/she is allowed to skip clinic
the afternoon before and the morning after the shift. Only two students may be
on call at a time. The schedule will be decided during orientation.
Weekend Responsibilities:
Each inpatient service (General and Stroke) must have at least one student to
round with the team each weekend morning, after which students are typically
dismissed. If a student has signed up for call on a weekend day, this will begin
after rounds finish. For students that are on an inpatient service the last week of
the rotation, there are no weekend responsibilities following the shelf exam.
Other Helpful Hints:
Review the neuro exam. You need to know it, as your ability to
recognize day-to-day subtle changes in the patient’s neuro exam is
important. Additionally, having neuro-specific exam tools such as a
reflex hammer and tuning fork is essential for this rotation.
Get good at reflexes during this rotation: The key is feeling the tendon
with your fingers, not just banging the joint and to distract patients with
another task, i.e., “squeeze your hands together” while doing patellars.
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Lesion localization is key to understanding stroke (1 week of your
rotation) and neurology in general. Suggested topics to review include
the basics of cranial blood supply, neuroanatomy, and neuroimaging
(CT, MRI, CTA, etc.).
The eWake website contains SOAP note templates for both the General
Neurology and Stroke services that are helpful for pre-rounding on
patients.
Attendance at lectures, grand rounds, and morning report is mandatory
(although attendance is typically not tracked via sign-in sheets).
Don't worry about the quizzes or paperwork in the rotation -- it may
seem hard, but everyone ends up doing really well on it.
Disease-specific advice:
For Parkinson's patients, think about their mental status, vision, tremor,
mobility and medication history/responsiveness and DBS -- perhaps
ask to do a UPDRS motor exam. Consider Parkinson’s plus syndromes.
For epilepsy, focus on the history of their disease -- when it first
presented, the type of seizures (clinical presentation and nomenclature),
medication responsiveness and compliance, other neuro sx (consider
syndromes), family hx. Don't worry too much about actually
understanding EEGs.
For stroke, it's all about localization and risk stratification -- and bleeds
vs. infarcts. Know the types of bleeds (SAH, subdural, epidural,
parenchymal hemorrhages) and what the risk factors are.
For neuromuscular/peripheral, get comfortable with how EMGs look in
neuropathy vs myopathy vs neuromuscular junction DZ. Know the
treatments for myasthenia and Guillain-Barré, and what kind of
supportive care you get for ALS.
For peds, just know the seizure disorders and all of the metabolic things
that can go wrong -- it's a super broad medical workup and is frankly
quite grim.
On the general service, be prepared to work up lots of encephalitis;
know the labs that go into that like HSV PCR, even the obscure stuff
like anti-NMDA receptor and syphilis. Know how to do a CSF
analysis. You'll get to do spinal taps. Don't be afraid of it.
Personal plug from Nick Coman: “Neuro is dope -- they're the most interesting
patients you'll ever see, and going into neuro in the 2010s is kind of like going
into aerospace engineering in the 1950s and software engineering in the 1980s --
it's literally the most important thing going on in innovation in our time... The
cherry on top is that it's a pretty low-key, fun rotation.
MS2016 Contributors: Nick Coman and Madison Shoaf
29
OB/GYN
Course Director: Dr. Jorge Figueroa
OB/GYN is a six week rotation with various experiences including Labor and
Delivery (two weeks), Maternal-Fetal Medicine, Antepartum/Mother-Baby,
Benign Gynecology surgery in both academic and private settings, Gyn/Onc and
Urogynecology, and outpatient OB/GYN. In general, these experiences vary
considerably from student to student and not every student will be assigned to
every rotation. In general, you can be expected to do two weeks of L&D and a
minimum of one week of outpatient OB/GYN, but the other weeks you are
assigned will vary.
In general, the residents' expectations are high. On Day 1, you’ll receive a brief
orientation by the course director, Dr. Figueroa, in Watlington Hall and that
afternoon you will travel over to Forsyth Medical Center for orientation to Labor
& Delivery and the Forsyth OR’s. Usually, the chief resident or one of the
attendings will go through the logistics and key information you should know on
the first day.
Labor and Delivery (2 weeks): Labor and Delivery can be a very busy service, depending on how many
mothers are in active labor and how many are in triage being assessed.
Sometimes it will feel like everything is happening at once, and others it will
feel like nothing is going on. You will have the chance to watch many
deliveries and should have the chance to catch at least one, but be proactive with
your patients! Once a mother is ready to deliver, the process can sometimes go
very quickly. Know where to get your gown and gloves and have them in the
room, so you can join the delivery team of your patient without delay.
You will have two weeks on L&D – one week of day shift (10 hours) and one
week of night shift (14 hours). You are permitted to nap during night shift if
little is going on, but if a patient you are following is almost fully dilated you
may miss her delivery. You’ll be expected to carry anywhere from 2-4 patients
at a time, depending on how many impending deliveries there are and how busy
triage is on the L&D floor that day. A good idea is to ask the resident when you
arrive which 1-2 patients you should pick up, and then try to follow new patients
as they come into triage. Keep in mind that some women go through labor
quickly and some go through slowly, so some patients that you follow for the
duration of your shift may not deliver before you leave for the day, and others
may deliver that you haven’t followed. You are allowed to stay a little late for
the delivery of one of your patients if it’s impending soon after you are
scheduled to leave for the day, but it’s requested that you make sure to not
violate duty hour restrictions by coming in later the next day.
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Usually, you will begin by delivering placentas, then you will deliver over the
resident’s hands and then work your way up to delivering the patient on your
own with the resident standing by.
On OB, the patients will need to be presented in a certain way and you will
quickly pick-up on this. There should be an outline in the orientation packet with
all this information. Put this in your pocket! Listen to your fellow classmates'
presentations and learn from their successes and their mistakes. There will be
some standard information requested on certain types of patients, such as those
with preeclampsia, preterm premature rupture of membranes, preterm labor, etc.
Be prepared and have the info ready on rounds. The basic opening line goes like
this: "Ms. X is a 34-year-old WF G5P4004 at 36 and 3/7 weeks gestation who
was admitted on (date) for (condition)."
Students are encouraged to help monitor patients in labor and aid them in both
their labor and delivery process. You are also encouraged to scrub in on as
many Cesarean sections are you can. While at Forsyth during either the day or
the night, you are encourage to participate in the two-hour cervical exam checks
on your patients so you can stay on top of what’s going on and increase your
likelihood of catching babies. Always remember to ask the four most important
questions (feeling fetal movement, contractions, vaginal bleeding, loss of fluid)
both during 2 hour checks and on patients coming into triage for assessment. It’s
also important to perform serial neuro exams (particularly reflexes) for patients
with pre-eclampsia or on magnesium.
Communication is really important on L&D so that deliveries aren’t missed and
notes are up to date. Bring something to read, because if your patients are not
actively laboring there may not be much else to do between 2 hour labor checks.
The best patients to practice your laboring cervical exams on are those who have
received an epidural; you can follow your resident’s exam and then compare
your estimated measurements to theirs.
Maternal-Fetal Medicine/High Risk OB (1 week): High risk OB is a service where moms are being followed for risky conditions
such as diabetes, preeclampsia or preterm labor. The residents keep a list of the
patients on service and each morning the day team will get a copy of the list
from the residents. Some of the patients are on antepartum status, some are in
active labor or delivery and some are postpartum status. It is the students’
responsibility to divvy up the high risk patients and write morning notes. Some
attendings want students to pick up all of the patients, while others only want
each student to pick up 2-3 patients. Ask the residents how many patients that
you should pick up on your first morning. During rounds, the resident goes
down the list and each patient is presented by the student that picked her up that
morning. This is always walking rounds. YOU ARE ENCOURAGED TO BE
CONCISE, complete and know what is going on with that patient. In the
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afternoons, you will go to the PAC and have at least one afternoon in the high
risk clinic.
Presenting the patients on MFM is similar to those on the L&D service – the
basic opening line goes like this: "Ms. X is a 34-year-old WF G5P4004 at 36
and 3/7 weeks gestation who was admitted on (date) for (condition)."
Even if not assigned to this service, everyone will follow a high-risk patient at
some point to complete a high risk log of a patient’s management (more
information during orientation).
GYN ONC (1 week): Some students will be assigned to one week of GYN Oncology/Urogynecology
and Pelvic Reconstruction. It is your responsibility to page one of the residents
the day before you start to find out when and where you should meet. You will
also have to contact one of your residents each afternoon throughout the rotation
to determine when the team will be rounding the next morning. In general, the
teams work out of the OB/GYN workroom in the Cancer Center (5C) behind the
nursing station by the rooms with the lowest numbers (and the big window).
You will follow the patients on the Gyn Onc service, and scrub in on the Gyn
Onc and urogynecology cases. Rounds usually start in the morning at 6, after
which you will go to your cases. Students can look at the white board in the
workroom to see what surgeries are planned for the week, and split them up.
You won’t always ‘round’ for afternoon rounds; it depends on the case schedule
for the day. The attendings like asking about anatomy and H&P things, so be
sure to know the patient and the procedures. Generally you will leave by 8pm at
the latest each day and will work one day during the weekend (typically
Saturday).
Benign Gyn (1-2 weeks)
Benign Gyn is divided into Forsyth Gyn and Baptist Gyn. For Forsyth Gyn, your
week will consist of observing surgeries, mostly by attendings who are in
private practice. The attendings are very friendly and love to teach. The
surgeries are pretty quick, leaving you lots of time to read about the upcoming
cases. There may not be a resident in all of the cases, which means you have an
opportunity to scrub in and help/be first-assist, so take advantage! Meet your
resident in the resident workroom at Forsyth around 6am. You will leave by
4pm at the latest, depending on the case. Read up on the next day’s procedures
to be prepared for questions in the OR.
Baptist Gyn is divided into clinic days over at Shepherd Street and scrubbing
into surgeries at Baptist. The cases are mostly staffed by an attending, an upper
level resident and an intern, so you’ll most likely be observing. These cases also
take a lot longer than the cases at Forsyth Gyn. Clinic days start a bit later than
OR days, but verify your start time with the resident before you begin. End
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times also vary depending on whether you’ll be in clinic or the OR on that
particular day. There are no weekends on Benign Gyn.
And, remember: review your abdominal/pelvic anatomy before the week begins!
Most of the pimping will be anatomy related.
Outpatient Clinics (at least 1 week) Clinic time will be spent at the Downtown Health Plaza at the WFUP OB/GYN
Clinic. Most residents at the DHP let the students see the patients first and then
will go back in with the student to do the pelvic exam and breast exam. You will
present your patient to a resident and/or an attending. You will do fundal
heights, fetal heart tones, pelvic and breast exams. Bring study materials just in
case clinic is slow, but don’t plan to use that time as study time. There is usually
much to do, and you will be disappointed if you think you’ll have time to read
your text.
Helpful Hints: 1. Though most of the lectures will be during the orientation week, you
will occasionally have a lecture, seminar, or teaching session during the
week. Make sure to keep track of where you are supposed to be and
when.
2. Be sure to patient track. You will also have a procedures card you will
need to get signed of procedures you complete during your outpatient
week(s).
3. Don't wait until the end of the six weeks to begin studying for your
exam; there are several objectives which you are expected to learn
about, and it will be tough to get through them all at the last minute.
Testing includes OSCE and an OB/GYN shelf exam on the last day of
the rotation.
4. Do your job and go to your assigned daily activities. If you skip out on
any of these, the course director will manage to find out eventually.
5. There is a small room for medical students on the L&D floor
affectionately known as the “Dog House” because that’s about how big
it is. You can study in there, but don’t hide in there with the door closed
because you may miss what’s happening on the floor.
6. When working up a patient in triage, it is also helpful to get previous
ultrasounds on patients (if available).
7. Check your schedule daily. There are a lot of different moving parts to
keep track of; each day has different places you need to report at
different times, e.g., grand rounds at Forsyth at 7 am on Wednesdays.
General Suggestions: 1. Be vigilant and enthusiastic. This is truly one of those rotations that
will let you slip through the cracks if you don’t keep up with your team
or the residents.
2. Always help your fellow students. This means helping out in the
morning to gather info for rounds (discretely) if you notice one of your
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classmates woke up late, or paging your classmate if you see that one
of their patients is about to deliver and they aren't in the room.
3. Acknowledge that to residents, all med students look the same. If there
is someone in your group who is trying to sneak out of responsibilities,
it will make everyone look bad.
4. Start putting on the appropriate delivery attire way ahead of time, even
if you get bumped out of the way. Even if the residents don’t look as
though the patient is about to deliver, there is a very good likelihood
that she can deliver at any time! There are more babies delivered on the
bed than you would want to know….which to a med student means a
missed golden opportunity!
5. Bring snacks. Forsyth has a nice cafeteria that is open late, but they
have limited options at late hours. There is a small refrigerator in the
medical student lounge.
6. If a resident is just hanging around at the desk, ask them to go over any
topics that you need to brush up on or found confusing.
EXAMS
On the last Friday of the rotation you’ll take the shelf in the afternoon. You will
also have an OSCE exam on either vaginal delivery of cervical exams the
second to last Friday of the clerkship. An in-house exam is being developed, as
well, for the morning of your last day.
TEXTS
1. Beckman’s Obstetrics and Gynecology. This text covers the ACOG
objectives on which the Shelf exam is based. It is also highly recommended by
the course director. A good overview, but long. Would definitely recommend
purchasing if you are interested in OB/GYN.
2. Case Files – Many students liked this text. It gives a quick scenario, asks
questions, has 2 pages of information, and a few comprehension questions.
3. UWISE – Online question bank provided by the department. Good USMLE
style questions.
4. Blueprints – Simple overview, good introductory text. Endorsed by many of
the attendings and residents.
Other texts students have used include OB/GYN Recall, Pre-test, OB Pearls, and
First Aid for the OB/GYN Clerkship.
MS2016 Contributors: Amber Carrier and Timberly Butler
34
PEDIATRICS
Course Director: Dr. Paul Sagerman
During the Peds rotation, you will spend 3 weeks on inpatient and 3 weeks on
outpatient pediatrics. The first day of your rotation is an all-day orientation
where you will get a lot of logistical information and even a lecture or two. You
will not get your schedule ahead of time and will only receive an individualized
hard copy. Talk with your classmates at orientation to see who will be working
on the same services as you.
Inpatient:
Inpatient General Pediatrics is split into 2 teams. While both cover general
pediatrics, Team A specifically also covers Pulm and Renal patients, while
Team B sees the Cards, GI, and Endocrine inpatients. Usually you do not pick
up specialty patients, but can if you want – especially if the general census is
low. Often, formal rounds do not occur with the specialty patients, so it is hard
to present them to attendings. Teams A and B alternate admitting patients during
the day, but alternate nights admitting. So one night Team A will take all
overnight patients, while Team B takes everyone the next night.
A typical day on the wards consists of coming in around 6 am for checkout and
pre-rounding on your patients (on average about 3 patients). Aim to be back
around 7 am to start working on your progress notes for your patients. This is
also the time when the upper level residents arrive and receive checkout, and
you can add anything you found on pre-rounds to help them out. Morning report
is at 8 am in the conference room on Ardmore 11, where both Teams A and B
gather, along with some of the other Peds services. Morning report consists of
case presentations by the residents. Some days you will have medical student
only morning report with an attending in the same style instead. Attending
rounds are after morning report and typically last a few hours. They are usually
family-centered rounds in which you present in front of the families, so don’t get
bogged down too much in numbers and make sure you cover anything sensitive
outside of the room before going in.
The rest of the day consists of noon lecture, grand rounds, medical student
lectures, and radiology conferences. Throughout the day the residents enjoy
teaching so be engaged with them on learning issues. Check up on your patients
in the afternoon!
While on inpatient you will work 2 weekend nights (usually in the 1st two weeks
of inpatient leaving the third weekend free). If you are assigned to work Friday
night, you will be excused from everything on Friday, and if you work Sunday
night you will have Monday off. Unfortunately, Saturday night you will not
have any days off. Show up for check-out in the evening and handle any
35
admissions that come in to the ED. Write some H&Ps to be reviewed by the
upper level on staff. They may also want you to make a brief presentation on a
topic in Pediatrics that interests you at some point in the night. Night call may be
changing to a full week rather than weekend days, so stay tuned for any updates
during your day of peds orientation.
Outpatient/Clinic:
Outpatient is broken down into three different services: Newborn Nursery,
Subspecialty, and DHP.
One week of the outpatient rotation is in the Newborn Nursery at Forsyth
Hospital, so know your Forsyth Epic password or have it ready to create. This is
a great opportunity to learn newborn exams and really augments your reading in
this area. Towards the end of the week, you’ll give a short presentation for the
team at the Newborn Nursery. You will also be evaluated on your newborn
exam skills by the attending. This is usually students' favorite week – you are
usually done by 12 or 1pm unless you are the student designated to “stay late”
(around 4:00pm). You will also come in one weekend morning to round.
You will spend a week in a Peds outpatient specialty clinic at WFUBMC (GI,
Cards, Endocrine, Renal, Hem-Onc, Genetics, etc). Arrange with your
department contact when and where to meet. If you have a particular interest
you may request it, but it is not guaranteed.
Pediatrics clinic at the Downtown Health Plaza is on the second floor to the
right. There is usually an abbreviated morning report at 8:00am in which you
have limited number of questions you can ask and labs to order to come up with
a differential diagnosis. Typically, students will do well-child visits consisting of
health maintenance/immunization checks. You will also do some “sick” child
visits, which tend to be lots of rashes and fevers. You may not see adolescent
patients unless they have very simple problems (this is resident/attending-
dependent). Spanish-speaking patients are usually off-limits too since it ties up
the interpreter for longer when working with a student. Just wait in the resident
room until a nurse brings a sticker back and sign up for that patient. Be sure to
find the appropriate development assessment form for the age of the child before
going in. Your responsibilities include taking a good history, doing the physical
exam, completing a development assessment form and then presenting your
findings to an attending or resident. After presenting, you and the resident
and/or attending go back to the room to see the patient. This provides a great
opportunity to sharpen physical exam skills. This is a great opportunity to learn
the components of well-child visits and appropriate levels of development for
children of different ages. Some tips include looking at the ears/eyes last in your
exam because little kids tend to get upset by those. It is good to be familiar with
developmental milestones and infant feeding recommendations to make your
PE’s and parent counseling more meaningful. If you know these things early in
the rotation, the staff will be impressed and things will go smoothly. Some
36
students may be assigned to spend a day in a community clinic as well, which
could be close by or up to an hour away.
There is an online database of 32 Pediatric clinical case vignettes
(“ClippCases”). You are assigned half of the cases during your outpatient month
and half during your wards month. You will have a quiz on the respective cases
at the end of each 3 weeks. They now only require you to do 28 ClippCases,
with 8 optional ones; however, there are still test questions from the optional
cases so you should review those, too. There is also an NBME shelf exam at the
end of your two-month rotation, which counts for 10% of your rotation grade.
Helpful Hints:
1) Learn metric conversions. Or know how to use a calculator.
2) Use old H&Ps: learn more about your patient, but don’t substitute this
for doing your own H&Ps because you may learn something about
your patient that is not included in the records, and that always makes
you look good.
3) It is best not to say that immunizations are “up to date” but instead
know which ones they had.
4) Give the maximum temp. for the last 24 hours (if it is relevant), and
indicate whether this was with or without acetaminophen.
5) Know the different types of formulas and the indications for their use
(calories, protein, etc). Also be able to calculate nutritional
requirements.
6) Know the differential diagnosis for fever in different age groups.
7) “Ins” are in cc/kg/day (should be about 100 cc/kg/day) and “outs” are
in cc/kg/hr (should be about 1 cc/kg/hr). (E.g., Divide the total urine
output (UOP) by the weight (in kg) and then divide by 24.)
8) Remember the Pediatrics mantra: Kids aren’t just little adults! Don’t
expect for the management of certain diseases to be the same in kids as
it is in adults.
Some Suggested Texts:
There is no recommended text, but many students have found the following
helpful:
1) Blueprints / Case Files / Pre-test Pediatrics
2) Nelson’s Pediatrics
Things to do:
1) Keep in touch with your resident about what the plan for the day is for
your patient. Inform residents of any lab/test results that have returned.
2) Read on your patient.
3) Do not wait until the end to do the ClippCases!
MS2016 Contributor: John Luttrell
37
PSYCHIATRY
Clerkship Director: Dr. Pedrag Gligorovic
The leadership of the psychiatry department changed in January of 2015 and
clerkship changes have been instituted both rapidly and ongoing. Be sure to
check with classmates who have been on the rotation recently to be updated on
changes. This is a 4-week rotation with lots of lessons on how to obtain a more
complete picture of your patients, coordinate auxillary services and many
opportunities to beef up on your pharmacology.
As of March 2015, students spent one week on each of four services: Adult
Inpatient, Child & Adolescent Inpatient, psych ED and Consult-Liaison. These
are detailed below. Each service was Mon-Fri, and students were on call for 2
weekend days over the course of the block. Each student was required to
participate in a 1-on-1 or 2-on-1 preceptorship. This included a physician
watching the student interview a patient for 20 minutes and then listening to the
student present a complete mental status examination report. Depending on
preceptor, groups met 1, 2 or 3 times. Each student was also required to present
a patient once in ‘case conference.’ This presentation was based on a patient the
student had interacted with in the psych ED and was given the week the student
was in ED—Don’t worry the presentations are fairly informal and low pressure.
There were weekly ‘case report’ sessions, each an hour long, which resembled
1st year CCL but were less structured and lower pressure. There were 3 sessions
of ‘chairman’s rounds’ where students watched a physician interview a patient
and were able to ask questions afterward.
Adult Inpatient This week varies greatly based on residents. Pre-rounding is only necessary if
you desire to be an active participant. Rounding takes 2-3 hours. The bulk of the
work for 3rd
year students includes assisting with writing notes, writing
discharge reports and gathering patient records. Gathering records is far more
cumbersome but also far more important than on other services. Patients often
come to the ED with nothing and in a state that precludes accurate reporting of
medical history. These records are often at myriad institutions and are tightly
guarded (rightly so), so faxing releases is required. Calling families is often the
only way to discover who your patient really is.
Child & Adolescent Be ready to be significantly troubled by some of the patients you will meet; it
can be hard to see such young people who have already gone through so much.
Little if any pre-rounding occurs. Rounds take all morning. Afternoons are over
quickly. If you choose to actively participate you can spend the afternoons
speaking with patients one on one. This often allows good practice asking the
38
questions related to diagnoses such as ADHD, which you will likely encounter
elsewhere.
Psych ED This is the place to see what a real manic or suicidal patient looks and acts like.
Take advantage of this opportunity. It is also your chance to interview patients
who are currently actively psychotic, hallucinating, and have not yet been
medicated to tamp down the psychosis. You may learn the difference between
someone telling you they are hearing voices to get a bed for the night and
someone looking behind them every 10 seconds to be sure a man in a black coat
hasn’t appeared in the room.
Consult-Liason
The pace of this service depends on the number of consults. You may see 1-2
patients each day or have several new consults who need full H&Ps. Checking
in on the overnight progress of your assigned patients as soon as you come in for
the day is very helpful to the team for planning and potential discharge purposes.
Rounds can take a while even if there are only 5 patients to see.
Texts:
For those who like outline form – First Aid for Psych Clerkship
For those who like answering Q’s – Lange Q&A
There were few if any shelf Q’s on legal ramifications. Focus more on the
differential diagnoses, teasing out things that can look the same. Know the
classic medical conditions that can cause psychiatry problems, and learn the
indications and side effects for the basic psychiatric meds, as well as some
simple pharmacology.
If you get through the Lange book, running through the UWorld or Kaplan
Qbanks is not a waste of time.
MS2016 Contributor: Aaron Winkler
39
EMERGENCY MEDICINE
Course Director: Dr. William Alley
EM is a 4-week rotation that is great for medical students in terms of getting
exposure to many different medical scenarios and getting to perform procedures.
Many students enjoy the rotation, whether they are interested in ED or not,
because there is lots of opportunity to be directly involved. It is notoriously
known as one of the best rotations of third year.
Unlike other rotations, you are assigned to 8-hour shifts. You will be the only
medical student working with a team assigned to a certain section of beds. Find
your resident, introduce yourself, and go see whichever patients they will be
caring for. Usually, your resident will ask you to see a certain patient, obtain the
basic history and perform a focused physical exam. (It helps to be efficient, as
the resident will need to come in afterwards to confirm your assessment and ask
more questions.) Then you will present to your resident. You will also want to
present to the attending at least a couple of times over the course of your shift,
so you can get feedback and have a basis for your grades.
N.B.: If you have a sense that a patient is really sick, don’t delay his care by
doing a full assessment; alert your resident. They will appreciate knowing the
situation before a patient goes into delirium tremens, for example…
The upper level resident and attending will evaluate you after each shift. Be
enthusiastic, willing to help and remember to provide reasoning for your
differential diagnoses.
You will work in both the adult and pediatric emergency departments. Most of
your shifts will be on the main floor of the adult emergency department. You
will also have a few shifts in the Fast Track section around the corner from the
main adult ED, which sees patients with less acute complaints.
Get excited! Many opportunities exist to present patients to upper level residents
and the attending and to work on developing differentials. There are many
chances to perform procedures, and if you become comfortable with simple
procedures you will be able to perform them independently.
Practical tips:
-Be on time for your shift! Your absence will be very obvious. Expect to wait a
little if you get there too early though, because another student will likely be
finishing his/her shift. A solid 5-minutes early is a good target, especially as the
Ardmore elevators are very busy.
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-Keep an eye on the ED track board. If your resident is busy, be proactive and
offer to see new patients who have been assigned to your section of beds.
-If a really interesting case rolls in (Trauma!), feel free to ask if you can get
involved even if the patient is outside of your assigned group of beds. But be
sure not to encroach on another medical student’s patient territory!
-This is the best rotation to complete as many procedures (in the procedure
curriculum) as possible so keep that on your radar. Do not expect anyone to
ask you to do any procedures. Be assertive and you will get to do a lot of
procedures. -Trauma shears are useful to have so that you can jump right in when traumas
arrive.
-Know where various supplies are kept, so you can take care of a patient’s needs
and nab procedures quickly.
-Communicate with nursing staff and your resident about procedures you want
to perform or have been told to do!
-When assigned to Fast-Track, let the PAs and doctors know if there are certain
chief complaints/procedures you would really like to see/do because they are
more than willing to help you get experience with things you haven’t seen on the
main floor.
-For podcasts, it can be helpful to download an app on your phone, so you can
listen on the go instead of being glued to a computer.
-Have a good differential and plan when you report to the upper level. The
podcasts are good for this.
-Learn what kinds of questions to ask for each chief complaint. These can be
related to different screening tools (CENTOR, Wells’, TIMI).
-If you are really in a bind to complete certain procedures towards the end of the
rotation, you can leave your pager number with the resident in triage and let
them know to contact you if xyz presents. (Again, if another student is working
in Fast-Track and needs to drain an abscess, don’t usurp his/her patient.)
What to read: A lot of students recommend Case Files. Also, the EM Basic
podcasts that the department asks you to listen to are helpful, as are the lectures.
Tests: The shelf at the end of the rotation is a fourth-year-level shelf, because
most medical schools have emergency medicine as 4th
year elective and not a
third year required rotation like Wake. Just do the best you can. The EM in-
house exam is doable using the lecture material from the rotation. Definitely
study the outlines from the EM Basic podcasts. As a heads up, there may be
weekly quizzes instituted rather than just one cumulative in-house exam; details
will be provided at the EM orientation.
MS2016 Contributors: Ashley Mogul , Dalton Tran, and Hillary Fitzgerald
41
SURGERY
Course Director: Dr. Amy Hildreth
Along with inpatient medicine, surgery is one of the two most important
rotations that residency directors assess. Even if you don’t want to be a surgeon,
a good grade and evaluation comments in surgery will speak to your good work
ethic and ability to work hard under duress – key personal attributes for any
future house officer.
Surgery is divided into 4 services - 3 weeks on General Surgery, 1 week Trauma
Surgery nights, 2 weeks on Subspecialty #1, and 2 weeks on Subspecialty #2.
Students interested in particular subspecialty services may be asked to write a
brief paragraph indicating why they are interested in requesting those specific
services. If you don’t get the rotation you’d like, rest assured that there is still
plenty of time to do an elective or AIM early in your fourth year to expose you
to the service and help you get a good recommendation.
Surgery is all about hard work. Getting to pre-rounds before your interns,
keeping the “list” accurate (more on that later), having the right things in your
pockets when asked for (more on that later, too) and tirelessly volunteering to do
stuff (see that consult in the Sticht Center, take on another patient, start seeing
patients in clinic before your attending arrives) will earn the admiration of your
interns and residents.
Somehow, you have to manage to work hard and study for the shelf exam which
is a benchmark with a certain score required for honors and for high pass. A
good way to study is to read all about your patients’ conditions. You should
also get a review book of your choice and try to do a few pages every day.
Each student is required to attend all Thursday afternoon conferences unless he
or she is on the night float shift that week. Make sure you do so, even if you
have to excuse yourself from the OR. Conferences are student led with each
person on the rotation presenting on an assigned topic for 15 minutes.
Surgical Recall is a good resource for answering “pimp questions,” and
depending on what rotation you end up on, you may get a lot of them. Always
read the H&P for every single case prior to entering the OR, as you may asked
for indications as to why the particular patients is getting surgery (as opposed to
other less invasive measures). You will also need to prep by studying the
anatomy and associated disease processes for each case. It may be helpful to
sketch the site and the important surrounding structures (muscles, nerves,
lymphatics, vessels, bones) on a 3 x 5 card and carry it in your scrubs into the
OR if needed or use your Netter’s flashcards. KNOW the layers of the abdomen
through the linea alba, since that is the route for any midline laparotomy
42
incision. If you’re getting frustrated by the questions, it’s fair to ask your
attending/residents what they suggest you read to supplement your OR
knowledge. You will inevitably be asked a question you don’t know the answer
to, and frankly, that’s why you’re there - to LEARN. So, if you don’t know an
answer, offer to look it up. In general it’s great to ask questions about the case.
You’ll have to get a feel for the residents and attendings that you work with, as
some of them might be annoyed if you are asking them a lot of questions in the
OR.
Since this is a long and important rotation, it is also important to schedule time
with your senior resident after 1-2 weeks to “check in” for feedback and what
could you do to improve. In general, the interns and residents are surprisingly
nice and will be helpful if you work hard for them. You can learn a lot of good
“intern skills” on surgery which may seem like scut, but you will be an intern
soon so you can think of it as job training as well!
This is a rotation that goes much better with a great attitude and much worse if
you dread it and just try to “survive”. The OR is a cool environment that has no
equivalent anywhere else. This may be the only chance you get to experience it,
so be fired up, be curious and you’ll be just fine.
Helpful Hints:
1. This is a busy rotation with high expectations for students.
2. EAT BREAKFAST! Come to think of it, try to eat a little something before
every case. It helps to always carry food in your pockets and keep a
toothbrush in your locker. Granola bars, peanut butter crackers, and raisins
are all edible in an elevator ride to the OR. Never plan on a case ending
when it should, some cases can take hours longer than expected and you’re
probably not going to be able to leave to get some dinner.
3. Study the anatomy around the surgery the night before the operation
(landmarks and disease processes more than specific techniques).
4. Don’t daydream while in the OR - they will catch you off guard.
5. Be ready to cut sutures by asking for the scissors and always have the
suction in your hand but don’t be too gung-ho with it!
6. Do what you can to help your intern but also realize that you can get taken
advantage of. Remember, the test is a large part of your grade.
7. Practice tying suture knots. You may get to suture, especially if they think
you are capable of it. If you feel comfortable, you can ask to suture or to
help close the wound.
8. Wear comfortable shoes, standing still for hours can kill you. Most
surgeons wear Dansko clogs or Crocs – both are worth the investment.
9. Be extra POLITE to everyone, especially the nurses.
Texts:
1. Supplied on Ophthalmology.
43
2. Pestana’s Notes – a short, succinctly written review of high yield surgical
topics. This book is extremely helpful for shelf study and for your clinical
knowledge!
3. Essentials of General Surgery by Lawrence (suggested text) can be very
helpful. It is a good overview of relevant topics, can be read over the 8
weeks, and is available in the library if you don’t want to buy it.
4. Surgical Secrets/Surgical Recall – these questions do come up. Most
students carried the Recall in their pockets. It is sometimes amazing how
the pimp questions are very similar to the “Recall” questions.
5. Surgery NMS: Good review, OR prep, & pimp lifeline.
6. Surgery Pretest: Good review of questions, but not a good reference for
pimp questions or OR prep. Probably won’t have time to read a good
review book and do the questions..
7. Pestana Review. This is a document with a ton of short clinical vignettes
for all of the major surgical specialties. It is a great resource for the shelf.
Get in touch with someone who has already done surgery and see if they
can give it to you.
Things to do:
1. Wear your name tag on your scrubs and introduce yourself to the attending
on the first day. The nurse who gets the supplies and keeps track of
paperwork during the operation is called the circulator. The nurse who
assists with the instruments is the scrub nurse. Introduce yourself to them
and ask them to teach you the names of common instruments if they’re not
busy. Always get your own gloves and give them to the scrub nurse (Know
your glove size!). Get your own gown too, although they will usually have
enough already.
2. Show interest by offering to do things, even if your offer is rejected.
3. Eat, sleep, and go to the bathroom when you can!
4. Read about indications for surgery, alternative treatments, the
pathophysiology of the disease process, and why the patient is there.
5. If your resident says you can leave, don’t second-guess, just go (study and
sleep time)! They really won’t think more of you if you ask: “Are you
sure?” so don’t say it.
6. KNOW THE ANATOMY! This is 75% of the pimp questions!
7. If you think you’ll need a step stool, try to place it near the table before you
scrub. You will undoubtedly always forget to do this.
8. Check the surgery schedule board during the day for time and room changes
- the case before yours may be running late, and you can use the extra time
to see patients, write notes, or read.
9. Remove your pager and place it on the counter or in your locker before
scrubbing. The circulator will appreciate this.
10. Ask where you should stand.
11. It’s good to have this stuff handy in your pockets:
Surgical scissors
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2” paper tape, 2” elastic tape
4” x 4” gauze pads and ABDs
Suture removal kit
Staple remover
12. Get disposable eye protection in the suture room and make sure you
remember to put them on before you start scrubbing
Things NOT to do:
1. Bump the sterile light holders with your head.
2. Be clueless about the current surgery.
3. Leave without permission.
4. Arrive late for anything at all.
5. Assume you get automatic food breaks.
6. Ask the circulating OR nurse to answer your pager when scrubbed in. They
will usually ask if you want them to return it.
7. Finish scrubbing before your attending - unless your attending is running
late, which does happen quite a bit.
8. Touch ANYTHING after scrubbing unless told to do so. Especially from
the Mayo stand - grabbing the scrub nurse’s toys won’t gain you any
friends.
9. Wear scrubs to clinic (unless you are coming from the OR).
10. Ask when or if you can go home.
Grades:
Based on shelf exam, clinical evaluations from residents and attendings, the
grade for your assigned 15 minute presentation on a surgical topic, and a graded
H&P which you will submit after your week on trauma/EGS night float.
Going to the OR: The OR is unique place and has special rules that are helpful to know for
Surgery and Ob/Gyn. When crossing the red line, make sure you have on
scrubs, shoe covers, a cap, and a mask. Be sure to either wear goggles or a mask
with a face shield for every case because you never know what will go flying in
the OR. They will orient you to scrubbing on the first day, but practice makes
perfect and always take your time. Generally, plan on using water for the first
case of the day and then AvaGard for the day’s subsequent cases or re-
scrubbing, but just follow the lead of your resident. Once gowned/gloved, don’t
touch anything until they tell you it is okay and then step up to the draped table
and place your hands on the patient. There is a 12” rule – if you are sterile keep
a foot away from anything nonsterile and vice versa; the scrub nurses will
remind you of this. Make sure you are ready to tie a suture since you might be
asked to do so on the first day. Lastly, pay attention, do not complain, and have
fun!
MS2016 Contributors: Andrew Usoro and Alexis Hess
45
General Surgery Services:
Most students pre-round and follow 3-5 patients at a time, depending on the
service/attending. Helping your intern get vitals, etc. is important so offer some
assistance in the mornings, especially if you have few patients you are actually
following. Student usually do not write notes but always ask the upper level
resident what he/she expects.
For most services, your main job as students is to update the team’s list (on a
computer in the COR). Learn how to use the computer to change the patient list
every morning. You can usually catch the overnight intern/SAR in the COR in
the mornings, but they usually will add anyone who comes in overnight. Some
residents are VERY particular about getting the list right each day. It helps to
periodically check everyone’s room number to make sure no one got moved.
On rounds, presentations are supposed to be short and to the point. Often, any
MAJOR overnight events and “afebrile-vital signs stable” is sufficient, but
always have the specific vitals available.
Colorectal: Overall, a busy service. Great learning experience, and highly recommended by
medical students, regardless of surgery interest. The attendings enjoy teaching
medical students if you show interest in learning. Pay attention to patient
presentations of inflammatory bowel diseases and cancers - they will help you
out on the test and in patient care.
Minimally Invasive Surgery - Laparoscopic/Bariatric:
A fairly busy service. Otherwise, they carry 10-15 patients. One skill you will
learn on this service is controlling the camera! (This means you have to pay
attention in the OR.) The attendings ask lots of questions! They also expect you
to make an informal presentation at the end of your four weeks about a topic you
encountered on the service; this is typically a good learning opportunity and not
high stress.
Surgical Oncology/Breast Care:
Great general service with good exposure to lots of diversity and general patient
management. The cases and hours can be long with days lasting from 5 am to 7-
8 pm most days. You will see lots of common cancers (breast, melanoma, colon
cancer) plus some zebras (pseudomyxoma, Merkel’s cell). Many patients have a
poor prognosis so you will see plenty bad news conversations and emotional
visits. Surg Onc attendings have fairly long follow-up, and their clinics are in
the Cancer Center - a sweet setup! Clinic is two days a week and can run late;
always ask about seeing patients on your own. The attendings will teach and
pimp a lot, will involve you in each case, and they have long cases. You will
46
probably be asked for a Power Point presentation at the end of the month. If you
don’t get as much OR time with an attending, that means more time to study but
could also mean more time to help with the scut work or cover the other
attendings cases if they are running two rooms or do not have another student.
Overall, this service has great attendings and you will learn a lot. This is a good
service to consider if you are thinking about surgery for residency.
Pediatric Surgery:
This is a demanding service for the medical student and is a good option for
someone interested in surgery or pediatrics. With Peds Surgery, you follow one
attending throughout the entire month and thus get a lot of face time with them.
They will know you well by the end of the month. Rounds begin early, usually
around 5:30 am so the student needs to be there by 5 am. Hours are long and
range from 5/5:30 AM to 6/7 PM. Prerounding is done as a team. If you are not
getting the numbers, the attendings tends to ask you what they are anyway, so
make sure you know what is going on with your patient. There is a pre-rounding
sheet that reminds you of everything you need to record, and copies are kept in
one of the cabinets near the physicians work area in the NICU. “Ins and Outs”
are also important to record for prerounds. Surgeries are generally not very long
and there is a good combination of common surgeries (ie: hernia repairs) and
rare surgeries (neonatal biliary atresias repair). The OR is warm, but not totally
unbearable and they usually turn the temp down a little during the case when the
patient is draped. Check out is scheduled to take place at 5:30 pm and can be
long if the census is long.
Key topics to know about include: hernias, pyloric stenosis, Hirschsprung
disease, gastroschisis, omphaloceles, necrotizing enterocolitis, and pediatric
nutritional requirements. Remember that the outer covering of the umbilical
cord is amnion. Know the spermatic cord layers and that children get indirect
hernias, not direct hernias. All of the attendings have high expectations, but you
will learn a lot from this rotation.
Transplant:
This rotation allows students to gain an adequate knowledge about the ins and
outs of the field of Transplant Surgery. Not only do you learn about the surgery
involved, but you learn about all the issues that are taken into consideration
when selecting transplant recipients. This rotation also offers a chance for
students to learn more about organ preservation, organ rejection, immunology,
immunosuppressive therapy, commonly acquired infections in transplant
patients, and prophylactic therapy. In addition to organ transplants, surgeries
include AV fistula creation and Tenckhoff catheter placement for dialysis
patients. There is "call," but you are only waiting for a page to see if there is a
47
transplant; you will not get called for random stuff, just major transplant
surgeries and generally these will just happen during normal morning hours
The Transplant Service can be a very busy one, with long hours, depending on
the length of the census and the availability of a recipient-donor match.
Variability describes the transplant service, so be flexible. Rounds depend on
the SAR and the surgery schedule for the day.
All of the attendings are great and enjoy having students. They also enjoy asking
a lot of questions! There is a mandatory 20 minute presentation given during
the 3rd week typically of each 4 week rotation by the student.
Trauma:
Students assigned to the Trauma/Emergency General Surgery (EGS) service will
spend time on Trauma Surgery and on EGS. Trauma is an exciting service that
truly is feast or famine—it can get really busy. Check-out from the night
resident is at 5:30 am, rounds are sit-down at 9 am in the conference room on 11
Reynolds, and some students round in the ICU. You are assigned an attending
who will evaluate you, but otherwise, the trauma team is one team with two
students (4th
year students are only in the ICU with the interns), an intern, and an
upper level resident. Make sure there is always a student at every OR case, at
every trauma code in the ER. Have you pager programmed to get the trauma
codes on your first day on service. At trauma codes you can become involved
by getting warm blankets for the patient (just keep putting them on the patient as
they may get thrown off a few times during the code – it is good to have the
blankets to keep the patient warm and to protect the patient’s privacy and
modesty), taking the history down from the EMS workers who bring the patient
in (residents will often be too busy running the code to get the details of the
history), and having the portable monitor ready and hooking it up when it is time
to transport the patient to the CT scanner, OR, or floor. Don’t be afraid to be in
the trauma bay during the code and help with anything that is needed – put the
blood pressure cuff on the patient, help to turn the patient when it is time to
examine the spine, do chest compressions if needed etc. Trauma codes are a lot
of fun to be involved with, so don’t just stand back and watch. Jump in and help
in any way you can. Students may be responsible for the list kept on the
computer in 5B which can get extensive. You may get to do a few procedures if
you hang around the ICU (change lines, put in A-lines, chest tubes, etc.). You
may ask the ICU intern to page you if he is going to do a procedure. OR time
is minimal if there are no traumas (PEGs, trach’s, colostomy take-downs, etc.).
You will spend your days either on 11 Reynolds or in the ICU. This rotation can
be really fun and exciting if you are flexible and available.
Emergency General Surgery:
In contrast to the trauma service, EGS is usually steadily busy. Check out from
the night resident is at 5:30 am in the COR. You will round in the morning with
your team, and some students pick up a few patients to present on while others
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do not have time to do so because they are in the OR even during morning
rounds. EGS serves as the general surgery consult service for the emergency
department and for floor patients on other services. This is a great service to
learn about wound care and common emergent surgical diseases such as
appendicitis, cholecystitis, bowel obstruction, and ischemic bowel. You will see
many appendectomies and cholecystectomies as well as trach and PEG
placements, irrigation and debridements, bowel resections, and hernia repairs.
You will learn a lot about surgical diseases from going on consults and will get
to see and do a lot in the OR’s on this service.
MS2016 Contributors: Andrew Usoro and Alexis Hess
Subspecialty Surgery Services:
Vascular Surgery: The vascular service has long surgeries, but a good and practical learning
experience on a core rotation exam topic and something you'll see forever in
practice. All of the attendings are great. Some like to talk about music, some
ask very detailed questions, some are big into research and want you to read
various journal articles, some are high energy and boisterous. You will be able
to see and touch a good amount of pathology and learn a great pulse survey, do
some wound care and amputation; There is lots of retracting time on these
surgeries, which usually pays off in suturing/stapling/other hands-on OR stuff.
One tip: ALWAYS wear goggles or a face shield on vascular; arterial and
large vein blood tends to spurt in the OR.
Burns: This service offers a good blend of ICU exposure and lots of OR time, plus
some trauma codes. Plan on getting vitals and labs for the floor patients before
rounds but you do not need to see patients on your own in the morning. You
will round with just the resident around 6:00 or so but they will tell you when to
show up. You may or may not round with the full team later in the morning.
The OR is notoriously hot and some of the cases can be very long, so prepare
yourself mentally and physically by drinking lots of water and Gatorade.
Besides being sweaty, the operations are often bloody/messy so you may need to
change your scrubs during the day and wear closed toe shoes. Doubling up on
shoe covers is also a good idea. The heat and long hours are physically taxing
and if you don’t have good physical stamina, don’t choose this rotation. That
being said, you really do get used to the heat and you get to do so much on your
own that the hours fly by. By the end of the first week you will be skin excising,
grafting, and stapling along with the team. One of the PAs will usually scrub on
all of the cases and they can teach you A LOT. Don’t just stand back; ask to do
something. If they are taking off the dressings on one leg, start on the other leg.
If they’re pulling off old allograft, grab a hemostat and start on another area. If
you are interested in surgery, this is a great opportunity to learn how to do
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things; however, you may not get to know an attending very well so plan on
using your other attending or an AI early in 4th
year for recommendations. This
can be an extremely rewarding rotation. You will get to directly treat patients
who have extreme injuries. In many cases, the work you do will play a role in
saving a life.
Neurosurgery:
The neurosurgery service is extremely busy at times and may require long
hours. Check-in rounds in the neurosurgery library are usually at 5:30 except on
Tuesdays and Wednesdays, when rounds are at 6 but always double check the
schedule with the chief resident. Students do not give presentations during this
time but may help by having vitals, ins/outs, and drain outputs ready when asked
for by the chief resident. You can participate when you get comfortable with the
speed of morning rounds and when you have relevant information to share. The
team typically covers 40-60 patients in 30 minutes during this check-in process
and so efficiency in the flow of information is emphasized. Always follow
along and take notes on your patient list.
Always ask how the team would like you to help and try to save your questions
for the morning floor rounds and while in the OR, after a case gets started. The
residents are great at answering your questions but just pick a convenient time.
Tuesday is academic day - there are lots of conferences and clinic. Some
students may choose to go to resident clinic on Tuesdays. However, you will be
required to go to attending clinics at least two half-days per week to get a better
idea about the practice of neurosurgery.
You are encouraged to scrub on operations that interest you. You do not have to
stick with a particular room or attending. Just don’t be seen too much in the
library or the cafeteria. Spend lots of time in the OR or in the attending clinics.
Always hang around for check-out unless a resident tells you very clearly to go
home. Checkout typically is by 6 pm but some days may be later. It’s usually a
good idea to find the intern or junior resident about 6pm because you probably
won’t get paged. The library is the main meeting place for rounds and
checkout.
Dr. Hsu will be talking to you at the beginning of the rotation about giving a 10-
15 minute presentation on the neurosurgery topic of your choice during the last
week of your rotation. You will want to find a topic relevant to neurosurgery of
interest to you and review the topic beforehand with Dr. Hsu. Your evaluation
during this month will be influenced by this presentation but also by your
interaction with the residents. Participating in the attending clinics will also
help.
MS2016 Contributor: Joseph McAbee and Alexis Hess
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Ophthalmology:
Some students call this the greatest surgery rotation available to the non-
surgeon. If you choose, you can have no nights, no call, and no weekends.
Your average day usually starts with surgery at 7am and you can stay in the OR
until late afternoon, or go up to clinic at 1pm-5pm. Wednesday morning grand
rounds at 7am are required attendance.
If you wish, let the resident on-call know that he or she can page you if they get
called into the ED (even then you may or may not get called). Some attendings
and residents are very nice and want to teach you (not as much scut work). OR
time is variable based on the students’ desires!
This is not an organized rotation as far as the students’ responsibilities are
concerned. At the beginning of the rotation Hannah McSawley will sit down
with you and go over the basics, but then she turns you free and you may feel
lost the first day. Try to meet with one of the residents to get the low down on
what they expect of you. Basically, in the AM, either go to the OR (you can
usually choose which OR case you’d like to see), or attend clinic with a chief
resident or attending. They suggest emailing the attending you want to work
with beforehand to let them know you’re coming to the OR. In the PM, clinic
begins at 1:00 pm. Follow a resident during his or her continuity clinic. The
chiefs are good to work with, and you’ll probably learn the most; ask the nurses
which resident will be in which room and choose accordingly. Dilated eyes will
be everywhere, so even if you don't get to handle a lot of the fancier equipment
you can become a pro at the regular ophthalmoscope and learn your way around
the slit lamp. Don't forget to make it to Dr. Weaver, Jr.’s pediatric clinic at least
once.
Most of the formal evaluation for this rotation comes from two events: 1) your
morning in the OR with Dr. Burden and your time in clinic with her the
following day. 2) Your presentation at ophthalmology grand rounds. You have
the opportunity to choose a topic for the presentation and work with a resident to
develop the presentation. Just know your topic well because they ask lots of
questions!
MS2016 Contributor: Sara Branson
Orthopedics:
Overall, it’s a fun month. This is a somewhat flexible rotation in that you can do
as little or as much as you want. Talk to Dr. Miller, the MS3 Clerkship Director,
before the rotation if you are interested in pursuing ortho. There are four
services that students may be assigned to: Trauma, Tumor, Hand/Upper
Extremity, and Foot & Ankle. Lots of OR time and cool surgeries. Trauma is
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often the busiest and most populous of the services, and you will typically be
there from 5:45 am until 6:30 pm. Surgeries are generally 1-4 hours, and you
WILL be pimped. Orthopedics is a rotation that can be busy or slow depending
on the specific service you are assigned and how many people choose to drive
their cars into trees plus how much you want to get out of it. If you get done
early, and are trying to make a good impression, other teams could always use
your help in the OR - regardless of which service you are on.
The best part about orthopedics is that most of the attendings and residents are
very friendly, and they will let you do some things (i.e. suture, put in screws,
etc.). Know your anatomy so you can get an idea of why they are doing some of
the procedures and so you can identify specific structures when asked.
Orthopaedics has become a competitive specialty, so if you are interested in
doing it, making a good impression on the rotation can go a long way. One
attending had this to say about succeeding on service - Adopt a mentality of
being the first one there, and the last one to leave. Be early, stay late, work hard,
be friendly, and you’ll do great. KNOW YOUR ANATOMY!
MS2016 Contributor: Ben Braun and Andrew Usoro
CT Surgery:
Rounds start at 6:00 a.m. in the CT ICU/ CCU. Rounds basically consist of
going through all ICU patients followed by the floor patients. There is a large
team that rounds in the morning which consists of the two CT Surgery fellows,
CT PAs, ICU residents + attendings, nurse practioners, nurses, pharmacists, and
social workers. In addition, there are senior level General Surgery residents
every other month. All these people meet at 6:00 a.m. for rounds. Rounds take
approximately a half hour in the ICU depending upon the patient census and
then approximately 45 minutes on the floor. Historically medical students have
needed to ask to present on rounds; depending on team preference you may be
limited only to presentation of floor patients (vs ICU).
After rounds the team goes to the OR; you may or may not have enough time to
grab something to eat prior. There are two to three operating rooms that run
every day; at least one of these ORs is dedicated to thoracic cases. As a student,
your main responsibility is to go into the operating room and scrub on the
surgeries that you wish to see. You should discuss with the chief fellow on the
service which procedure you are most likely to gain the most benefit from. If
you are interested in a particular case you will be allowed to scrub on that case.
(Pay attention to cases on the schedule that occur less frequently; there will
always be another time to see a CABG or a wedge resection.) You should;
however, be intimately familiar with the patient's history as well as have a basic
understanding of the surgical principals. You should also be aware of the
anatomy involved with the procedure. Know that attendings vary broadly in
style regarding their interactions with and expectations of students.
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Clinic: Clinic time varies by attending; try to at least attend a few cardiac and a
few thoracic clinics. Surgeons in general hate clinics so they frequently forget to
invite you outright but you’re certainly welcome to attend.
Approach to consults varies by fellow but often these patients are seen between
surgeries during the day. If you’re interested in going on consults (frequently for
things like chest tubes), be sure to let the fellow know because you will easily
miss out on them.
The physician's assistants on the service certainly are key members of the team
and are frequently the ones that you will interact with most often. They can help
you a great deal with basic surgical principals and techniques, so you should pay
attention to them and try to be as polite to them as possible.
There are two weekly meetings that the student is expected to attend. One is a
Wednesday morning meeting from 8:00 to 9:00 which is called CT Surgery
Grand Rounds. On Tuesday afternoons from 12:00 to 1:00 there is a Thoracic
Oncology Program where you will learn about lung cancers and mediastinal
tumors. Lunch is provided and it is on the 2nd Floor of the Comprehensive
Cancer Center. There are other meetings throughout the week and the chief
resident will go over those with you. You should make every attempt to attend
as many as possible to enhance your learning experience.
Resources/ Readings:
Free PDF Resource re: CT Surgery-
http://www.tsranet.org/resources/tsra-resources-for-residents/
[Before the rotation familiarize yourself with cardiopulmonary bypass
(the circuit and the procedure). You can check your understanding by
talking to the perfusionist during some downtime… or better yet elect
to sit with them throughout an entire case.]
MS2016 Contributor: Candis Jones
ENT: Walking rounds start at 6:00 am. There are 2 or 3 teams, and you will be
responsible for writing the daily SOAP note on 3-5 patients on one of those
teams. The residents really appreciate having those couple of notes done prior
to rounds, and it helps you learn about the patient, their problem, and
management. Students have no other responsibilities with the patients on the
floor. Students can generally make up their own schedule based on interest after
discussing it with the resident medical student coordinator on the first day of the
rotation. You will probably have one to two days a week of clinic time and the
other days in the OR. OR time depends on the attending, and Drs. Brown,
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Sullivan, and Waltonen often do cool oncology cases. Try to rotate your time
between the inpatient and outpatient OR's...If interested in Peds, Dr. Kirse's and
Dr. Evans' cases and clinics are very interesting and not all tonsillectomies and
ear tubes!!! The coordinator tries to make sure you see most of the broad range
of what an otolaryngologist does and integrate with some things that the student
is particularly interested in. Great residents; they have fun and get along well
with each other. Try to ask questions to make it interesting and get involved.
Lots of conferences, all required. There is a weekly one-on-one lecture with the
student and a resident. The hours can be very long if the ENT service is on
trauma call (2 weeks of every month), or short if not on trauma. There are a lot
of really neat operations that go on. The down side is that the students really
don't get to do much depending on the case. You will likely be of most
assistance in the head and neck or trauma cases. You often can help the resident
close and get some suturing practice. If you take the initiative to be "on call" on
a trauma night or weekend, you will get more experience suturing facial lacs. It
can be very difficult to see what is going on in some of the operations since they
may take place in the back of the throat or inside the nose. The monitors and
cameras in the OR do allow you to see more of the endoscopic and microscopic
cases. It's a busy service with a lot of cases. You will get a lot out of it if you
take the initiative to get involved and help out the residents.
MS2016 Contributor: Matt Rohlfing
Plastics:
Generally, this is a pretty fun service and is quite hands on. This is not the
service for you if you don't like being in the OR. Know face and extremity
anatomy. Students generally show up around 5:45 am to begin rounding on
patients. Students do not follow their own patients. Rounding would typically
last until 6:30am at which time the residents would run the list. Students
typically do not write notes on the floor patients. Afterwards, students generally
will go down and will be in the OR for the rest of the day. You can help in the
OR by positioning, moving and transporting patients. Read about the patients
before the case and you will get more out of your time in the OR. The more you
participate, the more the residents will let you do. Practice knots and interrupted
sutures (ask to take unused sutures from the OR). Pay particular attention to
deep interrupted sutures and running subcutaneous sutures. These two sutures
will be the most commonly asked sutures for students to throw. Most surgeries
are hand, burns, breast (reductions, reconstructions after mastectomy),
microsurgery (flaps for wound reconstruction), or facial. All the cosmetic
surgery is done as outpatient surgery. Occasionally, you will be asked questions
by attendings. Most of the questions will pertain to the relevant anatomy for
each surgery. Residents like to teach whenever possible and are generally a fun
group to be around. The day ends whenever the last case in finished, usually
around 5 pm (range 4-7 pm). There are no nights unless you volunteer (because
you want to go into plastics or are crazy). Generally students do not come in on
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the weekends, but the option is still there. Attending clinics run throughout the
week. Most of the experience is shadowing but it is a great way to get more face
time with the attendings. Just ask the residents about the clinic times. Great
rotation overall that is a favorite among students.
MS2016 Contributor: Tommy Xu
Urology: The residents are willing to teach, and happy to have students around. There are
three teams in the urology department, two adult teams and one pediatric team.
Typically you’ll spend time in clinic and the OR. You are generally in the OR
all the time except for Friday afternoons, when you help the residents out in the
clinic for uninsured patients. There are a variety of operations to scrub in on,
open cancer surgery, laparoscopic and robotic prostatectomies/nephrectomies/
cystectomies/urinary diversions, stone/Endourology, female/incontinence and
pediatrics- reimplantation of ureters. The chief residents usually ask you to
arrive at rounds around 6 am. There is no pre-rounding required for medical
students. There is no call, but you are expected to stay at the hospital until your
team finishes with all surgeries and with evening rounds. You will be required
to attend the, Wednesday morning grand rounds and Wednesday evening's
multidisciplinary cancer conferences. Important topics to read up on during the
month are bladder cancer, renal cell carcinoma, incontinence, BPH, prostate
cancer, and GU reflux for pediatrics. Before your rotation, please contact the
urology academic office at 336.716.5702 for the chief resident's pager, the chief
will give you additional information as where to report on your first day of
rotation. Typical day during OR week goes from 6 am to approximately 6-6:30
pm. Typically, you show up to clinic having read upon your pateints at 8 am,
and you will likely stay there till the last patient leaves, which happens around 5
pm. Clinic responsibilities consist of doing HPIs, presenting patients to the
attending and coming up with your own A/P. You are not required to write notes
on EPIC.
MS2016 Contributor: Sij Hemal
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NOTES
