1. How to be a Good GREAT 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

7. 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

8. What makes a good student? 1. Knowledge 2. Good CSI Skills 3. Kindergarten Skills

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

10. 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

11. 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….

12. 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

13. 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

14. 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

15. 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

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

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. What are my responsibilities as a third year student? Let’s walk through the day….

19. Your first day… Get 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

20. Different “uniforms” for different services You may not need a tie or a white coat on some services, but would confirm this before not doing so Only wear scrubs outside the OR if ok’ed with resident and attending first

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. 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 Nurse, family concerned about patient

26. Responsibilities…Before Rounds 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

27. Responsibilities: On Rounds 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….) Be the EXPERT on your patients

28. On Rounds… the presentation Stick to the format (SOAP) Stick to the problem list Run the plan by your intern/resident before rounds Have a plan

29. Responsibilities: On and After Rounds 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

30. Responsibilities: After Rounds Af ter 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 Write notes, work on discharge summaries Sign out before leaving, go over list, updates and any other needs

31. Sample “to do” list O check on blood cultures – call micro lab if needed O follow up second ck at 2 pm O follow up on cardiology consult O call primary care physician and make sure appointment is made for follow up

32. Follow up (tests, procedures) 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

33. Organization Data, vitals, labs, skeleton note for the day Prior data/notes from other days Admission history/physical Admit medications and current medications All attachments All labs (today and prior, with baseline for creatinine, hgb/hct) Family/contact information To Do list

34. After Rounds: Follow up notes 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

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

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

37. Other work activities after rounds Working on discharge summaries Calling and following up with consults Helping with medication review and reconciliation Any clinical work (orthostatics, pulse oximetry, ambulation, etc)

38. 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

39. Summary Points Do not assume (dress, responsibilities, duties) Do not obsess about “scut” – provide care needed to your patient Do not worry about “pimping” Stay organized, read, ask, get feedback, work hard and you will be noticed

40. Questions…