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Tips, tricks, advice for being a medical student on the wards

Many students feel disoriented in their first clinical years attachments and the cycle continues with each subsequent attachment. To some extent this is inevitable as you will need to work out how the team conducts their day. This thread is for tips on how to get the most out of your ward attachment.

Here’s a short list off the top of my head. There will be more to come as I (and others) think of them:

    • On the related point, the best way to learn is to offer to do things like ‘can I try presenting this ECG’, or ‘when we get a chance can you watch me do a cardio exam’, you get much better learning if you put some effort in too. Passive learning from your registrar is comparatively much less useful and a bit unfair to the registrar.
      • If there’s something you don’t understand then make a point to try and understand it. Registrars are often quite willing to explain things unless they’re too busy doing something else or it’s a vague question that isn’t practical to answer while you’re walking down the corridor. A good way to ask a question is to give your own explanation for it and ask the registrar if it’s right. If there’s a broad topic that you don’t understand (e.g. what are the causes of a low Na+) ask the registrar if you can learn about it tonight and try and explain it to them tomorrow. This is a good principle throughout all of medicine, make some effort yourself before asking someone else to do it for you.
      • Always turn up on time, being late will very quickly typecast you as the lazy medical student. The day normally starts with ward rounds or handover and you should aim to be there every day for that. Typically it sets the scene for the rest of the day and you’ll be behind if you miss it.Anticipate areas where you can be helpful. On the wards this might mean writing in the patient notes (once you feel comfortable doing so and have the permission of your registrar or intern), finding and describing the obs chart, carrying pieces of paper you might need around with you like consent forms in surgery, progress notes, path request forms etcThe central goal should be to create a role for yourself as a team member. Aim to help the team if you can, in return you’ll have the gratitude of your seniors and probably better teaching when you ask for it. This means:
    • Never, ever lie. Not to registrars, your intern, or your patients. A good principle to follow in medicine is to tell things like they are. Concise, simple, don’t beat around the bush.
Something I still struggle with is lying about examinations. If I don't feel something straight away I tend to lie about feeling it. However I'm very quickly learning that the emphasis is now changing from passing the exam (where pretending to feel it cuts it), to actually being a good doctor. So today after struggling to feel the fetal back (rather then the front), I actually said 3 times, "no I cannot feel it". The consultant was actually really friendly about it and helped me feel it, and once I found it it was really easy to see what I was looking for. So yay. <br />
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Still not lying about stuff is still a bit hard particularly when I'm nervous.
    I thought I'd quote a list of 'unwritten rules' from medscape to this thread. I think they're useful, although, I also think they're fairly simple and that there's much more I and others can add to this thread in time.<br />
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    <blockquote><br />
    <span style="font-weight:bold;">1. Do not take anything that happens in the hospital personally.</span>The hospital is a high-stress environment. Many situations that arise as you rotate -- for example, issues with unhappy patients, doctors who disagree with other doctors -- will be completely new to you, and you will not be sure how to handle them. No matter the situation, make sure you act professionally at all times. In particular, a common problem for students is learning to accept criticism from interns, residents, and attendings. Try to focus on the reason why you are on the rotation: to learn! Try to accept constructive criticism with a smile because it will ultimately make you a better doctor.<br />
    <span style="font-weight:bold;">2. Read! Read! Read!</span> We cannot overemphasize the extreme importance of keeping up with information. <span style="font-style:italic;">This is the only way to impress your attending -- with what you know!</span>We realized how easy it was to neglect our studies, but we made it a priority to read constantly on our rotations. It quickly becomes apparent when you do not read on clinical rotations, and you quickly realize how much you do not know. You cannot afford the luxury of <span style="font-style:italic;">not</span>studying.<br />
    <span style="font-weight:bold;">3. Do not expect every attending physician to be a teacher.</span>Although we know it is our attendings' responsibility to teach, we also came to realize that we will meet only a few <span style="font-style:italic;">good</span>teachers. Let's face it: Many of us are going to become attending physicians someday, and we cannot assume that everyone knows how to teach well. It is a skill, and the attending must be willing and able to do it. As for us, we learned a lot from the doctors who taught us and we read up on the rest.<br />
    <span style="font-weight:bold;">4. Be on time to every rotation. In fact, getting there early is safer and better.</span>You can spend some time reading the charts until your intern/resident arrives.<br />
    <span style="font-weight:bold;">5. Be professional in your attire and in the way you carry yourself.</span> Remember, these physicians will fill out your evaluations and possibly write you a letter of recommendation for your residency application. They will remember you, so always leave a good impression.<br />
    <span style="font-weight:bold;">6. Ask for letters of recommendations early.</span> Doctors are busy and can take months to write a letter.<br />
    <span style="font-weight:bold;">7. Read up on your patients' conditions, especially if they have a diagnosis that you are not familiar with.</span> You should be able to understand what the doctors are discussing.<br />
    <span style="font-weight:bold;">8. Do not ask questions if you can look up the answers.</span> Jot down your questions somewhere so that you don't forget them, and look them up when you get home. It looks bad if you ask simple questions that you should know or can easily research.<br />
    <span style="font-weight:bold;">9. Study early.</span> Remember, you have a shelf exam or school exam at the end of each rotation. This test usually counts as a big portion of your rotation grade. These clinical grades are important for when you apply to residency, so you want to do really well on them. Also, you have 2 board examinations at the end of third year: the clinical knowledge and the clinical skills exams. Thus, studying early is crucial.<br />
    <span style="font-weight:bold;">10. Strengthen your residency applications (and don't put this off).</span> Keep up with the work; we started working on our curriculum vitae right after taking the boards. You will need this to request a letter of recommendation from your attending physicians. It is also important that you find tangible projects or research to pursue which will help strengthen your residency application. </blockquote>
      Medical students are often in a position where they can act as scribe for their registrars or consultants, otherwise it is the intern. This is a clinical skill, however, it is not well taught before attachments. Doing it well improves patient safety and care, it improves the regard other people will have for your professionalism and diligence, and it may mean the intern is more likely to let you do it rather than only feeling comfortable doing it themselves.<br />
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      There is an acronym for writing in the notes, very simple, but widely used - <span style="font-weight:bold;">SOAP</span>. It stands for subjective (what the patient tells you or the history), objective (what you find on examination and the results of investigations or imaging, assessment (what you think is going on with this patient - a very useful part of the notes but something often missed out), and plan (what you're going to do in your endeavour to diagnose and/or treat the patient's problem). This is basically how you should organise your notes.<br />
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      Housekeeping involves date, time, and (at the very least) name of the most senior doctor present. For example:<br />
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      <span style="font-style:italic;">17/07/11 S/B Smith (geris consultant)<br />
      1020</span><br />
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      That would probably be the bare minimum housekeeping, you might also add 'with team' or the names of the other doctors (registrar, intern) etc. S/B stands for seen by, in general you should avoid acronyms and the like but on a hurried ward round recognised ones such as this will save time.<br />
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      <span style="font-weight:bold;">Subjective</span> (often titled in the notes as Hx - history) in a daily progress note will not so much be a full history (this should have been done in the admission note), but an update on the last 24 hours. Typically, and especially with an older medical and surgical population, it will involve questions about pain and the five key bodily functions - bowels, urine, eating, drinking, and walking*. The risk for medical students is writing down detail nobody cares about (e.g. patient complaining about noise from the bed next to him).<br />
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      <span style="font-style:italic;">*note</span>: if ever the registrar asks you to go and start seeing a patient while they organise something or if you're asked to do the ward round for a patient and you have no idea what to ask pain and those five things will almost always be appropriate, assuming admission notes have already been completed (and they should have been).<br />
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      <span style="font-weight:bold;">Objective</span>this follows a fairly set format. Start with a quick sentence on appearance e.g. patient not distressed/looks well/looks unwell/is disoriented to time/place/person etc.<br />
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      Next is the vitals, usually garnered from the observation chart. Record heart rate, blood pressure, resp rate, saturations (if necessary), and temperature. In some patients (e.g. surgical patients) you might also include drainage volume, fluid balance charts, blood glucose level etc.<br />
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      The rest of the physical exam depends on the patient - e.g. an orthopaedic patient might include something about a wound, surgical patients almost always have their abdomen examined on the ward round, medical patients usually have their lungs listened to - often their heart and abdomen are also examined.<br />
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      Next is relevant serology (again patient dependent) e.g. a CRP is relevant to most patients who have had or might have an infection and is recorded over time, Hb is very relevant to GI bleed patients, INR might be important in a patient on warfarin etc. etc.<br />
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      ECGs, and imaging are also considered here.<br />
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      <span style="font-weight:bold;">Assessment</span> is probably the hardest for the medical student to record because the registrar will often not actually state their opinion and you have to work it out from what they've said/done. Sometimes this is very easy, sometimes it isn't.<br />
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      <span style="font-weight:bold;">Plan</span> this is usefully divided up into Dx plan (plan to obtain diagnosis) and Rx plan (plan for treatment) but in practice it's usually just plan. Again this is a difficult one because the registrar might say something like we'll start him on antibiotics but the notes should really be as specific as possible (e.g. ceftriaxone 1g IV daily) so as to aid the nursing staff and those who read it afterwards. <br />
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      Another important note is some things need to be explicit, for example - daily weights or TEDS stocking (DVT prophylaxis) are sometimes omitted despite being referred to in the notes.<br />
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      <span style="font-style:italic;">Note:</span>It is very useful, although often time doesn't permit this, to discuss with the nurse looking after the patient what their concerns are and what your priorities for the patient are. Arguably you save time by doing this as you keep everyone on the same page, again, in practice, the nurse might be busy, on break with another nurse covering, or unaware that you're around. Still, better to chart the fluids the patient needs then and there rather than being called back, for example.<br />
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      <span style="font-style:italic;">Note2:</span> If ever you write in the notes and you include a plan you need to make sure you have the notes counter-signed as a medico-legal requirement. You yourself also need to sign and record your name and position on every set of notes you write in so it is obvious that it was a medical student and not a doctor who wrote those notes (even when you get it counter-signed). If you don't include a plan then your signature, name, and position are probably sufficient (even then it's nice to have it reviewed by a doctor) but you have to be very explicit about this so it is obvious that a set of notes (which should look very similar to doctors notes) are in fact medical student notes.
        <blockquote><span style="font-style:italic;">Note:</span>It is very useful, although often time doesn't permit this, to discuss with the nurse looking after the patient what their concerns are and what your priorities for the patient are.</blockquote><br />
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        More a hint for interns than medical students, but it is almost essential that you do this - be it during the ward round, or soon after. The nurses don't trail after the clinical team and read the progress notes religiously after the round (they are busy too), so verbal handover is an invaluable thing to get into the habit of doing often, and well, very early on. If something needs to be done urgently, it is acceptable to temporarily break from the round to let the nursing staff know right away.
          I think this is a really interesting article to read about. A day in the life of a junior doctor: everyday ethical encounters. Something that you'll all be exposed to and while, in a lot of cases you won't be able to change anything, I think reading this might aid with perspective about the small things you can do everyday to become a more ethically responsible student or doctor.<br />
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          As a medical student, be keen, be seen.<br />
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          Ask questions and do your pre-reading. If you interest your tutor in helping you learn, you'll do much better. Being in medical school is building the foundation of knowledge, basic science and communication/analytical/attitudes you'll carry through when you start working. With the increase in medical student numbers and less hours worked, experience is becoming less. If you're not keen, your tutor will likely be more interested in completing his/her clinical duties or clinic than to teach you.<br />
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          As for medical records: once a week - do a nice summary (half a page).<br />
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          e.g. 67 year old, lives alone at home admitted with # left NOF. Day 1 post hemiarthroplasty (left) (usually age, reason for presentation, premorbid status)<br />
          Major issues:<br />
          1. Wound ooze<br />
          2. Major active comorbidities (insert here)<br />
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          Relevant major Ix result if need follow-up (e.g. Hb 82 - for transfusion today)<br />
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          Plan: Trial of void today. Weight bearing as tolerated. Continue physio. Aiming for discharge to rehabilitation hospital in 2-3 days once wound is healthy. (current plan, discharge plan and ETD)<br />
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          Just remember: <span style="text-decoration:underline;">everyone</span> talks about you if you're bad. Nurses will tell the interns and registrars about you. The doctors all talk amongst each other. You'll be amazed how easy it is to find out whether your student has been the ward (eg ask the patients, the ward registrar/rmo). <br />
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          The only real way to fail a clinical attachment unless it has an assessment (that you fail) - is really don't turn up, offend someone, do something dangerous, or being just plain lazy with an attitude problem.<br />
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          Always hand over to the nursing co-ordinator after a ward round and if you make any changes to the plan (e.g. medications) - let the nurse looking after the patient know - they will always write it down for their own nursing handover. Good communication makes you friends. That - and chocolate + coffee. Blessed be the intern who includes me in their coffee run on the way to work.
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