How to be a Good GREAT Third Year Student on the Wards…

1. How to be a GoodGREAT Third Year Student on the Wards… Debra Bynum, MD Prior third year UNC Medical Student (1992)

2. Heard in the physician work room this last week…. • She is a really good student… One of the best I’ve worked with all year…. (from a third year internal medicine resident….)

3. WHY?

4. From the Resident… • She was always available • She always had a great attitude • She always read about her patients • She always did things to help; she did not disappear in the afternoon to study for her tests… • She picked up more patients than assigned; even patients she did not pick up, she came to the ED with us to see the patient, learn, and just to help • She understands the “big picture” • She is great with patients and families

5. What the resident did NOT say… • She got all honors for second year • Her board scores were out the roof… • She always out-answered the other student • She knew all the answers

6. Bottom Line: The Good and the Bad • Attitude and energy can make or break you • What you know is important, but how you act and demonstrate your knowledge is even more important • Excellent first and second year medical students may not always have an easy time during third year (subjective evaluations) • Students can shine during clinical years

7. What makes a good student? • 1. Knowledge • 2. Good ICM Skills • 3. Kindergarten Skills

8. Bottom Line… • If you energetically try to provide the best care for your patients, you will be a good student and a good doctor

9. What does this mean? • Know your patient well • Read about your patient’s problems and learn how to take care of your patient • Make sure your patient gets good care – be their advocate • Communicate your patient’s needs to the team

10. About “Scut” • There is NO scut work related to the care of your patient • If your patient needs a lab draw, vital sign, form completed, help getting out of bed – then it is important • The story of Dr. Parker….

11. DO NOT ASSUME • Do not assume that what your patient needs will actually get done • Do not assume your team knows what you do • Do not assume to know what your team expects • Do not assume your patient knows what is happening

12. ASK • Ask about call • Ask about pre-rounding • Ask what patients to pick up on first day • Ask about conferences, schedules • Ask about notes • Ask how you can help

13. What can I do to make a good impression? • Be positive • Be pro-active: Offer to do what is needed before you are asked • Offer to do small presentations for the team • Look up articles for the team and share • Help interns, residents and other students on the team

14. What can I do…. • Go and see and evaluate as many patients as you can – even those patients you will not be “following” • Ask about call: If overnight call is not required, offer to stay late or overnight for at least one call night for each rotation

15. What can I do… • Dress neatly and appropriately • Do not chew gum • Do not carry food or beverages on rounds • Always be professional, even if others are not

16. What can I do… • Pay attention on rounds, even to other patients and other presentations • If you are bored, do not look bored… • Ask the right number of questions • Be available • Read about your patients • Ask to help out with notes, orders, forms

17. What can I do…. • Ask to help out with clinical “scut” work: • Pulse oximetry with ambulation • Make sure patient gets to their test (go with them) • If they need to be NPO, make sure they are • Make sure a patient gets up out of bed to a chair • Get orthostatics when needed • Bring samples down to the lab in acute events • Scrub in for surgery and procedures

18. Follow Up • Make sure the plan for your patient is carried out • Do not assume it will happen • Ask the nurse • Call down to the procedure site • Make sure transportation happens • Let your resident/intern know if there is a problem

19. What can I do • Be on time for rounds, lectures, meetings • Do not try to make the others look bad • Be nice to staff, nurses, HUC’s • Be respectful to and of patients, families and visitors

20. What are my responsibilities as a third year student?

21. Pre-round on your patients • What is needed will vary by clerkship • Anticipate 10-15 minutes per patient (longer initially) • Touch base with your intern or resident

22. Each morning…. • Vitals • Overnight events (from nurse and overnight intern/float): TALK TO THE NURSE • Subjective issues from the patient • Physical exam findings (for the day) • Labs and other data • Consult reports from prior day/evening • Any radiology/tests that came back the day before

23. Each morning…. • Check the MAR for current medications

24. Pre-rounding • Information to know: “Attachments” • IV and Central lines • Foley catheters • Telemetry box • Restraints • SCDs

25. Responsibilities… • Develop your problem list with a plan for the day for each problem • Record the above data each day – this can serve as a template for your morning presentation and progress note • Meet with the intern/resident before rounds to review plans for your patient

26. Responsibilities • Prepare your oral presentation (practice) • Present to the team on rounds (3 minutes) • Keep follow up sheets of data in large, spiral bound notebook so you have easy access to prior days, labs, medications, etc (It is NOT cool to have thousands of cards flying out of your pockets on rounds….) • Help write progress notes, orders, discharge notes, prescriptions • Be the EXPERT on your patients

27. Responsibilities • Know your patient • Know ABOUT your patient • Read about all of the diagnoses for your patient • Know the anatomy before going into surgery • Anticipate questions (“Pimping”) • Don’t freak out about “pimping” – it is an excellent way to learn when done correctly

28. Responsibilities • After Rounds • Keep a “to-do” list • Stay organized • Follow up on the to-do list! • Be available!! Let the team know if you have a student conference or meeting you have to attend • Sign out before leaving, go over list, updates and any other needs

29. Responsibilities • Your goal is to learn and improve • Ask for Feedback • interns • Residents • Attendings • Patients/families

30. Notes and Presentations: SOAP • Subjective • Patient complaints, overnight events, pertinent positive and negative ROS • Eating, pooping, peeing, walking…. • Objective: • Vitals (fever, ins and outs, oxygenation) • Physical exam (pertinent findings and changes) • Labs, xrays, studies

31. SOAP…. • Assessment • Summary statement • Stick to the Problem List • Plan • Talk to your resident/intern beforehand • Have a plan for the day!!

32. KNOW MORE THAN YOU WRITE, WRITE MORE THAN YOU SAY…

33. Other tips for the presentation • Stick to the format • Stick to the problem list • Run the plan by your intern/resident before rounds • Have a plan

34. The Look • Wear your white coat and badge • Things to carry • Notebook with patient information, pens • Rounds report for patients on your team (even patients that are not “yours”) • Clinical “pocket” book for the rotation (ask) • Sanford guide/pharmacopeia • Scissors (esp on surgery) • Reflex hammer • Light • Stethoscope

35. What if….

36. What if my patient looks really sick when I go to pre-round • Use your gut – if someone looks really sick, call your resident • Red Flags: • Fever • Increase pulse rate • Shortness of breath • Chest pain • Increase in respiratory rate • Decrease in oxygen saturation • Change in mental status • Decrease in blood pressure • Severe pain

37. What if… • The nurse is really concerned or worried… • Go get your resident or intern; trust the nurse’s instincts as well as your own

38. What if… • You Have Fun • Learn a ton • Help a patient