how to be a good great third year student on the wards… debra bynum, md prior third year unc...
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How to be a Good GREAT Third Year Student on the Wards…Debra Bynum, MDPrior third year UNC Medical Student (1992)
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….)
WHY?
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
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
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
What makes a good student?
1. Knowledge
2. Good ICM Skills
3. Kindergarten Skills
Bottom Line…
If you energetically try to provide the best care for your patients, you will be a good student and a good doctor
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
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….
DO NOT ASSUMEDo 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
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
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
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
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
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
What can I do….
Ask to help out with clinical “scut” work:
Pulse oximetry with ambulationMake sure patient gets to their test (go with them)If they need to be NPO, make sure they areMake sure a patient gets up out of bed to a chairGet orthostatics when neededBring samples down to the lab in acute eventsScrub in for surgery and procedures
Follow Up
Make sure the plan for your patient is carried out
Do not assume it will happenAsk the nurseCall down to the procedure siteMake sure transportation happensLet your resident/intern know if there is a problem
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
What are my responsibilities as a third year student?
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
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
Each morning….
Check the MAR for current medications
Pre-rounding
Information to know: “Attachments”
IV and Central linesFoley cathetersTelemetry boxRestraintsSCDs
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
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
Responsibilities
Know your patient
Know ABOUT your patientRead about all of the diagnoses for your patientKnow the anatomy before going into surgeryAnticipate questions (“Pimping”)Don’t freak out about “pimping” – it is an excellent way to learn when done correctly
Responsibilities
After Rounds
Keep a “to-do” listStay organizedFollow up on the to-do list!Be available!! Let the team know if you have a student conference or meeting you have to attendSign out before leaving, go over list, updates and any other needs
Responsibilities
Your goal is to learn and improve
Ask for FeedbackinternsResidentsAttendingsPatients/families
Notes and Presentations: SOAPSubjective
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
SOAP….
AssessmentSummary statementStick to the Problem List
PlanTalk to your resident/intern beforehandHave a plan for the day!!
KNOW MORE THAN YOU WRITE, WRITE MORE THAN YOU SAY…
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
The Look
Wear your white coat and badge
Things to carryNotebook with patient information, pensRounds report for patients on your team (even patients that are not “yours”)Clinical “pocket” book for the rotation (ask)Sanford guide/pharmacopeiaScissors (esp on surgery)Reflex hammerLightStethoscope
What if….
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:FeverIncrease pulse rateShortness of breathChest painIncrease in respiratory rateDecrease in oxygen saturationChange in mental statusDecrease in blood pressureSevere pain
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
What if…
You Have Fun
Learn a ton
Help a patient