1. How to be a Good GREAT Third Year Student on the Wards… Lindsay Wilson, MD MPH Prior third year UNC Med Student (2006) Adapted from…. Debra Bynum, MD Prior third year UNC Medical Student (1992)

2. Bottom Line… If you energetically try to provide the best care for your patients, you will be a good student and a good doctor But this is all new to you and you will need to know how to act like a great 3 rd year until you actually become one!

3. Fake it Until you Make It! What does this mean? Look the part How does a “good” third year medical student appear? Act the part How does a “good” third year medical student act?

4. Look the Part Dress should be clean and appropriate for a busy day in which you will be in close proximity with patients and colleagues Wear your ID badge and keep a reference book handy Have a good pen, pen light, stethoscope and any other supplies applicable to your service Keep snacks/drinks/gum limited to physician workspaces (not on rounds and in patient areas even if your attending does it!)

5. Act the Part Orienting Pre-Rounding Before/During Rounds After Rounds

6. Orienting… Who? Someone may be “designated” to orient med students—this could be the intern, resident, fellow, NP—a good place to start may be the most “junior” person but always confirm with the people “more senior” who will be doing the evaluation When? Early! First or Second Day if possible, then after 3-4 days check in again Where? Resident work room (not the OR, patient room, etc)

7. Pre-rounding What is needed will vary by clerkship and will somewhat be learned via “osmosis” but asking helps! 30 minutes Anticipate 30 minutes per patient when you first start Three people to talk to—the intern/resident, the patient, and the nurse Overnight events or big news (from nurse and overnight intern/float) Subjective issues and questions from the patient

8. Pre-rounding o Physical Exam: Will depend on the service, patient issue (ex. Patient with CHF) o Don’t report findings you didn’t actually find or look for o Do the “basics” until you feel comfortable doing otherwise

9. Pre-rounding Information to know: “Attachments” IV and Central lines*^ Foley catheters*^ Telemetry box Restraints SCDs Drains*^ Tubes*^ *what is the output/input ^how long have they been in For all of these attachments—when can they be removed??!??!

10. Pre-rounding: Things to Discover from EPIC Vitals (know ranges, maxes, and currents) Labs and other data (know trends) Medications—(know doses of insulin, PRNs, days of antibiotics, new start medications) Consult reports from prior day/evening (take- home message) Any radiology/tests that came back the day before (summary of findings)

11. Before Rounds Prepare your oral presentation (practice ahead of time!) Run your plan by a team member (intern, NP, resident) Communicate your patient’s needs to the team Appropriate time/place With respectful deference to your colleagues expertise and obligations

12. For example. What if my patient looks really sick when I go to pre-round Use your gut – if someone looks really sick or worse than expected, call your resident Red Flags: VITAL SIGNS! Shortness of breath Chest pain Change in mental status Severe pain Nurse, family concerned about patient

13. On Rounds Present to the team on rounds (3 minutes) Look organized (It is NOT cool to have thousands of cards flying out of your pockets on rounds….) Stay engaged How can you help? What is going on with other people’s patients?

14. On Rounds Stick to the format (SOAP) Stick to the problem list Run the plan by your intern/resident before rounds Have a plan It is OK to be wrong! Should not be “call (insert specialty here) consult”

15. After Rounds Know your patient Know ABOUT your patient Read about the diagnoses for your patient Know the anatomy before going into surgery Anticipate questions (“Pimping”)

16. About pimping Used to stimulate thought on rounds, keep team active and engaged Question “types” can vary depending on the attending May be used for evaluation of knowledge, particularly if you fall outside of the “normal” expected knowledge for your training level More likely to be used for evaluation of effort—if you look you are trying, great! If you look bored, super- competitive, argumentative, “out-of-it” not good…

17. After Rounds Be available!! Let the team know if you have a student conference or meeting you have to attend (sign-out before leaving) 1. Stay organized 2. Follow up on the to-do list! 3. Notes

18. 1. Organization It may take awhile to find your “system” Different people have different approaches For me colored pens, check boxes, copies of H/Ps really helped Again, learn to find what you need in a way that is efficient and appears effortless

19. 2. 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

20. Sample “to do” list  perform medication reconciliation  follow up second set of cardiac enzymes at 2 pm  follow up on cardiology consult  call primary care physician and make sure appointment is made for follow up  family meeting  check I/Os at 2 pm—if not net negative 0.5 L talk with intern about re-dosing lasix  walk with the patient in the hall and check O2 sats

21. 3. 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

22. 3. Notes Assessment Summary statement Stick to the Problem List Plan Have a new plan for the day!!

23. A good rule of thumb… KNOW MORE THAN YOU WRITE, WRITE MORE THAN YOU SAY…

24. Finally, what can I do to act like an All-Star? Be positive: Soak in the “culture” of your team and specialty Be pro-active: Offer to do what is needed before you are asked Be academic: Offer to do small presentations for the team, Look up articles for the team and share, Be on the look-out for case reports and/or mentorship from attendings

25. Key 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

26. Questions…