Let’s get clinical

The ABCs of clinical rotations: Always be curious

An OMS IV offers her tips on excelling in clinical rotations. Chief among them: Ask questions, know your patients, carry snacks.

My very first four-week clinical rotation was at an outpatient family medicine office. Two weeks before my start date, I emailed my preceptor with several questions about how to prepare for the rotation: When should I be there? What should I wear? What should I bring? What textbook should I read?

The day I started, I arrived to the office in my freshly pressed white coat with my brand-new medical bag stuffed with equipment and classic pocket textbooks about clinical medicine; I arrived 45 minutes before the office even opened.

I was nervous and excited to get out in the field. I wanted to see how all of the information I had crammed into my brain over the first two years of medical school pertained to actual medical practice.

Like many medical students, I spent my first year of school tucked away in cadaver labs, libraries and classrooms, establishing the knowledge base that would help me make sense of the clinical pathology I would learn in second year.

During my second year at the Midwestern University/Arizona College of Osteopathic Medicine (MWU/AZCOM) in Glendale, I cranked up the intensity, hunkering down in my year-old academic bunker, preparing for the day when I would sit for the ominous first-level board exam.

For me, third year was the reward: After two years of being a full-time student, I was elated to spend my days interacting with and learning from patients, physicians and ancillary staff. That is, I was ready to start learning by doing.

Challenges of clinical rotations

But the first clinical clerkship year can be daunting for any medical student about to start applying classroom lessons to real-world patients with legitimate health concerns. And although first-level board exams may be over, third-years must continue studying for second-level exams while also planning their future in medicine.

Moreover, students are no longer in a structured academic setting with a schedule of lectures, exams and study-group meetings. Instead, they are working with medical teams and preceptors, subject to others’ schedules and expectations.

My third year was rich in personal and professional growth. I loved working in the clinic and the hospital, learning patients’ stories. By my third month of clinical rotations, I knew I wanted to be an internist.

Some of my classmates, however, found the transition from classroom to workplace more challenging. They weren’t getting the ward-based experiences that may have helped them choose what type of medicine they wanted to pursue, they said. Others, who missed the structure of the classroom, complained that attending physicians did not teach. Some just did not play well with others.

The challenging thing about third year is that, more so than first and second years, your experience is highly dependent on your attitude and willingness to work hard and learn for the sake of learning.

“Third year is what you make it,” says Emily M. Allex, OMS IV, who attends the University of New England College of Osteopathic Medicine in Biddeford, Maine.

Although I may have waited 30 minutes outside a locked office on the first day of third year, I hoped I made an impression: I was the type of student who was going to hit the ground running.

Advancing knowledge

Studying for first-level exams had wiped me out, as it had many of my classmates. In the days following the exam, I did not want to open a book or watch another online medical education video.

Thank goodness for my third-year clerkships, however, for they introduced me to new study aides: Patients motivated me to open books, read and learn more.

Later in third year, I had a patient with alcohol withdrawal and cirrhosis. He had the classic presentation of delirium tremens. Moreover, his skin was jaundiced. His eyes looked like those of a Halloween cat; they seemed to glow yellow. He had spider telangiectasias on his chest. His abdomen was distended, and I could even make out caput medusae. I could not get much of a history from him, but when I went home that night, I read about alcohol cirrhosis and withdrawal. The next day, I knew a little more about his pathophysiology, his expected course and treatment plan.

“Always read about your patients,” says Aman Verma, OMS IV, who attends MWU/AZCOM.

If students see enough patients and read repeatedly about specific cases, they will strengthen their knowledge base and may contribute more to patient care. By the end of third year, students may be acting more like interns, making medical management recommendations and teaching others about patients.

While books may be your friends for life, medical students should take the opportunity to engage the teachers they have on hand: the ancillary staff, the attending physicians, the patients and their peers. Asking questions demonstrates your interest in patient care and medical management. Volunteering to do pretty much anything—making phone calls, manual disimpaction of stool, applying pressure to a femoral wound following removal of an intra-aortic balloon pump (IABP)—may create new learning opportunities.

Building relationships

I stood at the bedside of an intubated and sedated patient, my hand shaking from anxiety and my own muscle fatigue. I had been applying pressure to the patient’s femoral artery for five minutes. I had to be exact: too much pressure would impede flow to the leg, too little pressure would not allow for hemostasis. After my five minutes, my fellow classmate would apply pressure for five minutes; we switched off as the nurses and intensivists in the unit stood by watching.

The third year of medical school is also about re-engaging society and building relationships.

On clinical rotations, medical students represent their institutions and their peers. They are also creating connections with people who will one day be their colleagues. Residents and attending physicians will need to refer patients to primary care or specialty physicians; how will they remember their former medical students just starting their own practices?

Third-year medical students may not be prepared academically or clinically for all of the patients they encounter, but they have some control over how they present themselves professionally to others.

First impressions matter, and a person’s general appearance can broadcast a message. Wrinkled, smelly, holey white coats convey a lack of hygiene and respect for this symbol of continuing medical education. Passive learners may appear lazy and careless. Students who mumble their way through patient presentations seem insecure. Those who are consistently tardy may be considered disrespectful and lacking regard for the time that physicians, staff and patients take to teach students.

“Be on time,” Allex says. “And even if you’re on time, you may be late.”

But even if students are the most punctual, well-dressed, well-mannered and polite professionals in the hospital, they are still medical students; they are there to learn. Staff and physicians may criticize and chastise students—at times without apparent reason—though most of the time they mean to teach. For me, I tried not to let personality differences get in the way of the learning experience. I focused on my own weaknesses and asked others how I could improve.

“Be willing to accept criticism,” said Thinh Tang, OMS IV, who attends the Touro University Nevada College of Osteopathic Medicine in Henderson. “Do not take anything personally.”

So as my classmate and I applied pressure to a patient’s femoral artery, one of the intensivists approached. Stern and unsmiling, he asked, “Who are you guys?”

We told him: We are enthusiastic medical students who had never seen or participated in an IABP removal.

Cultivating you

Before medical school, I had a typical 9-to-5 job. As a health and science reporter, I enjoyed reading and talking about medicine, but I also had plenty of time to pursue other interests. I had nonmedical friends, and we would meet up for happy hours on weekdays and visit museums, go to movies and run in the park on weekends.

Then I got into medical school, and my love of medicine grew. By my third year, I was updating friends and family about seeing procedures and participating in patient care.

Clinical clerkships can be fun and captivating, but they also may take over medical students’ professional and personal lives.

After two years of absorbing as much as possible from books and lectures, I was so excited about every patient encounter I had during my third year. Using my stethoscope to listen to people’s lungs, hearts, and stomachs thrilled me. I would go on hikes with fellow medical students and all we seemed to talk about was our most interesting cases, our frustrations with electronic health records or our study techniques for the monthly exam at the end of each rotation.

Although I was more social during my third year, I didn’t learn a ton about what else was happening in the world. I would go out with nonmedical friends and find I had nothing to share that did not involve some internal organ. Eventually, my friends and I would limit all medical conversations to the first five minutes of a social outing.

“Have hobbies outside of rotations,” Verma says. “Don’t let rotations consume your life.”

Remember, the third year of medical school is also about helping medical students determine who they are and what type of physician they want to become. As students advance through their third year, contemplating fourth year and the residency application process, they have to consider what they value personally.

Regardless of how much time students spend studying, networking or socializing, the third year of medical school should remind them why they wanted to become physicians.

At least for me, third year gave me the opportunity to explore my varied interests in medicine. My clerkships exposed me to different people and social situations, and they made me evaluate what kind of doctor I wanted to become and what kind of medicine I wanted to practice. Always curious about people and their stories, I viewed my third year as a chance to ask questions, challenge my clinical skills and learn from anyone and everyone.

3 comments

  1. Unfortunately clinical rotations often serve as the Achilles heel of osteopathic education. When clinical training takes place at small community hospitals and outpatient clinics students miss out on exposure to a lot of pathologies and different sub specialties. Fortunately there are fourth year electives but I think this is a major deficiency that needs to be addressed

  2. In response to IJR

    Well good thing one year doesn’t determine your whole medical education. But I agree. It is probably the biggest challenge of osteopathic medical education. But some would argue that rotating in places where you are one one with the physician is beneficial. The best Osteopathic schools provide avenues for both types of learning, but this should be the standard of every osteopathic school, not just some.

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