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

6. 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

7. What makes a good student?
1. Knowledge
2. Good ICM Skills
3. Kindergarten Skills

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

9. 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

10. 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….

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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. 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

19. 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

20. What are my responsibilities as a third year student?

21. Pre-round on your patients
What is needed will vary by clerkship
Anticipate 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. Check the MAR for current medications
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. 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

26. 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

27. Responsibilities 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

28. Responsibilities Keep a “to-do” list Stay organized
After 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
Sign out before leaving, go over list, updates and any other needs

29. Responsibilities Your goal is to learn and improve Ask for Feedback
interns
Residents
Attendings
Patients/families

30. Notes and Presentations: SOAP
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

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

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

33. 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

34. 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

35. What if….

36. 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

37. 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

38. What if…
You Have Fun
Learn a ton
Help a patient