This time of year is almost universally overwhelming for visiting medical students at away rotations. They are thrown into a new environment for a brief amount of time and there is a great deal of pressure to impress both faculty and residents. After years of hard work and study, these few weeks may be one of the most influential aspects of a residency application. A survey study of Emergency Medicine (EM) residency program directors by Crane et al. showed that EM rotation grade was the single most important factor in resident selection.1
Given the importance of performing well on this rotation, how do you succeed? Or equally as important, how do you NOT fail? This blog post was developed as a culmination of advice from personal experiences combined with those of the ALIEM 2015-16 Chief Resident Incubator, a network of over 200 chief residents from 71 programs across the country. While some of these tips may appear obvious, the potential anxiety associated with this high-stakes rotation causes many of these issues to still occur every month at programs across the country. Follow this advice to demonstrate your best self and avoid the problems that may easily overshadow many others.
[su_spoiler title=”1. Don’t Be Late” style=”fancy” icon=”chevron-circle”]
“If you’re not 10 minutes early, you’re 10 minutes late.” Be 30 minutes early if that is what it takes, but don’t let the thousands of hours of work devoted during medical school go to waste because you showed up 5 minutes late to receive sign out. Emergency Medicine is a specialty of shift work. Arriving late demonstrates a lack of respect not only for the patients in the department who are waiting to be seen, but also for colleagues who are waiting to go home.[/su_spoiler] [su_spoiler title=”2. Don’t Lie” style=”fancy” icon=”chevron-circle”]
The temptation will be there, perhaps more strongly than ever before. Audition rotations are stressful, as is the burden to try to always appear impressive. There will come a time when the senior resident or attending will ask about that one detail of the patient’s history or that one specific physical exam and you are going to be mortified realizing that you forgot to obtain it. A lie may present itself as an easy way out. Don’t do it. First, it won’t work. The lie will be exposed as soon as your supervisor sees the patient him or herself. More importantly, even a simple lie calls into question your trustworthiness and character. Better to admit the oversight and offer to address it immediately. This demonstrates an ability to acknowledge mistakes and creates a teaching moment as to why that specific history or physical exam point is important for that case.[/su_spoiler] [su_spoiler title=”3. Be Nice” style=”fancy” icon=”chevron-circle”]
Success in Emergency Medicine relies heavily on being able to work well with all members of the care team in a professional environment. Understand that you are being evaluated by everyone with whom you come in contact – residents, interns, nurses, techs, clerks, consulting services, and, perhaps most importantly, program coordinators. Be supportive of your fellow rotators as well. While it is important to read and be prepared for your rotation, be careful about being overzealous. Demonstrate knowledge without being a gunner or putting down others. This is an audition to see how you will be as a resident – as such, assessment is based not only on patient care, but also on you as a potential future colleague. Pay attention to details, complete paperwork on time, be professional, be humble and be respectful to everyone.[/su_spoiler] [su_spoiler title=”4. Don’t Forget Why You’re There” style=”fancy” icon=”chevron-circle”]
As a rotating medical student, you may observe fellow students focus their energy on making friends with residents and attendings, believing that this will increase their chances of matching. While it is nice to be social, when you are in the ED, you are there to work. Remember that the goal for this, as with any other, rotation should not be to stand out socially, but rather, to provide the best patient care possible. This will impress far more than any casual conversation.[/su_spoiler] [su_spoiler title=”5. Perfect Your Presentation” style=”fancy” icon=”chevron-circle”]
As a medical student, the expectation is not to be able to perform a cricothyrotomy or run a resuscitation, but to be able to do a thorough history and physical exam and demonstrate strong communication skills. Davenport et al. argue that the majority of a supervisor’s impression of a student is linked to how well that student gives a medical presentation.2 An efficient, thoughtful and well-organized presentation may be the best thing to differentiate one student from another.
Tips to Refine Presentation
- Stick to the Script – Communication in medicine is standardized and medical providers are trained to think about patients in a uniform manner, starting with history of present illness, and progressing through physical exam, assessment and plan. Diverging from this script creates confusion, appears disorganized, and disengages your listener. Don’t bounce around; rather tell the story your audience is expecting to hear.
- Stay Relevant – You should know everything about the patient – allergies, medications, surgical history, etc. – but only present what is relevant. Junior level medical students often give every detail of a patient’s history because they do not know what is relevant. Don’t fall into this trap as it makes for a very long presentation and does not highlight your thought process. If the supervisor needs more information, they can inquire, but start by presenting only what you think is important. The best way to do this is to take some time to organize a differential diagnosis before presenting and then provide the information to confirm or refute each possible diagnosis within your presentation, focusing on pertinent negatives. As an example, when a medical student presents a patient with chest pain and notes that they have no leg swelling, no recent immobilization, and no history of thromboembolic disease, it clearly demonstrates that pulmonary embolism is on the differential diagnosis before even addressing it explicitly.
- Commit – It has been suggested that medical students often progress through a series of stages referred to as the RIME criteria (Report, Interpreter, Manager, Educator). Most learners begin in the reporter stage, but as you enter your clerkship, you should strive for the interpreter or manager level, focusing on developing a differential diagnosis and management plan for each patient. Progression through the various stages of RIME has been associated with higher clerkship scores.3 Students often spend too much time trying to guess what a resident or attending might want. Instead ask “what would I do for this patient if I were all by myself?” It is okay to be wrong, but it is not okay to avoid the thought process. An assessment and plan, even a bad one, helps the supervisor to understand your thought process and identify potential learning opportunities.
There are a number of resources recommended by Chief Residents to polish your presentation skills, including:
- The 3-Minute Emergency Medicine Medical Student Presentation
- EM in 5: Patient Presentation
- RAPID Tool
Emergency Departments are extremely busy places that require a great deal of teamwork to be successful. Even as a student you can be an integral part of that team. Look for patterns and try to predict the needs of your patients and of the department in general. For example, if a sick trauma patient presents to the ED, find the ultrasound machine and bring it into the room. While some may see this as service over education, it demonstrates an understanding of the needs of the arriving patient, helps with patient flow, and puts the student in a position to perform the FAST ultrasound exam and have a front row seat to learn from the resuscitation. Additionally, as a visiting student, you will be in a new environment. Therefore, take time early in the rotation to familiarize yourself with the equipment storage rooms. Unless it is an emergency or time-sensitive, try to be self-sufficient and look for equipment on your own before asking for help. Similarly, learn the name of the staff with whom you will work – especially helpful can be knowing the name of the charge nurse, pharmacist, and social worker.[/su_spoiler] [su_spoiler title=”7. Have a Goal” style=”fancy” icon=”chevron-circle”]
Prior to your rotation, consider your strengths, weaknesses and opportunities for growth. Asking for help or direction in a certain area of your practice is not an admission of incompetence, but quite the opposite, as it shows insight into your own education and a commitment to lifelong learning. Defining a goal for each shift, as well as for the rotation as a whole helps to focus your learning efforts and guides supervisors to maximize your benefit from the rotation.[/su_spoiler] [su_spoiler title=”8. Be Enthusiastic” style=”fancy” icon=”chevron-circle”]
We all know that some shifts can be less stimulating than others, but it is important to remember that each patient and shift present multiple learning opportunities. Stay busy and look for things to do – practice starting peripheral intravenous lines, do a literature search about a relevant topic, or read up on the other patients within the department. While some residents, attendings and staff may speak poorly of patients or situations, as a student it is critical to avoid any contribution to such negative comments. One of the appeals of academic medicine is the exposure to the excitement of junior learners – be positive and show this off as it is inspiring and helps remind everyone why we love this field.
Lastly, remember that an “audition” rotation is just as much a program auditioning for you as the other way around. Reflect on your experience and think about what kind of a learning environment you need to thrive. Your sub-internships are an amazing opportunity to see how emergency medicine is practiced at different institutions – embrace every learning opportunity and it will build a strong foundation for your residency training.[/su_spoiler]
- Crane JT, Ferraro CM. Selection criteria for emergency medicine residency applicants. Acad Emerg Med. 2000;7(1):54-60. PMID 10894243
- Davenport C, Honigman B, Druck J. The 3-minute emergency medicine medical student presentation: a variation on a theme. Acad Emerg Med. 2008;15(7):683-7. PMID 18691216
- Ander DS, Wallenstein J, Abramson JL, et al. Reporter-Interpreter-Manager-Educator (RIME) descriptive ratings as an evaluation tool in emergency medicine clerkships. J Emerg Med. 2012; 43(4):720-7. PMID 21945508