By Anisha Reddy, MS4
Third year of medical school is an exciting time–you finally get to transition from your preclinical to clinical years of training. It’s the first time you are part of the medical team making the clinical decisions! A lot of emotions surround the beginning of third year–excitement, nervousness, fear, and uncertainty. A year ago, I was in your shoes trying to navigate third year and below I will share the lessons that I learned to become my best version of a student and tackle the shelf exams!
Remember, it is easy to get overwhelmed in the beginning of the year/ beginning of each rotation. The learning curve is steep in third year. However, the year gets better as rotations go on and you gain more clinical skills/knowledge. My first rotation of 3rd year was surgery, and I was so overwhelmed. Everyone around me seemed to understand the medicine and surgical procedures so well. I had to remind myself that they all have years of experience over me! You will get there, I promise, if you put in the time to learn. If you do not understand, ASK questions, because this is your time to do so. You are paying to be there, so maximize your learning. Read up on topics you do not understand. People will throw around many acronyms and drug names that are unfamiliar. If you do not know what they’re talking about, ask or look it up. By the end of third year you will be familiar with the most common brand names of drugs. It comes with time so do not worry. You will be impressed by how much you have learned and grown from the beginning of 3rd year to the end. Keep an open-mind about each specialty. It’s ok to change your mind and decide to pursue a residency in a different specialty than originally planned!
Third year grades typically comprise of a clinical score–determined by the attendings/clerkship director (that you worked with) during each rotation plus a shelf score. The shelf score is standardized, however the clinical evaluations can be subjective. I’ll discuss study techniques and clinical skills to make you a star student.
Most importantly: add Spoonful of Sugar podcasts to your studying for each rotation :). For each rotation, UWorld will be your number one resource! You will find 2-3 general resources you like and use them as the backbone of studying for each rotation. UpToDate is a fantastic resource to look up diseases, treatment plans, drug dosing, etc. It’s like your google for medicine but better. See if your hospital has a subscription to UpToDate and use it!
Surgery
Clinical advice: On this service, you will spend the majority of the time in the OR. Read up on each surgery before you enter the OR. Having a general idea of the operation will allow you to follow the procedure better and answer questions well. Which takes me to ‘Pimp” questions! Frequently you will be asked questions about the procedure or topics relating to patients seen on rounds. Answer to the best of your knowledge; it’s ok to say “I don’t know.” Ask your residents how you can be helpful and the expectations of the rotation. Periodically ask residents and attendings for feedback to improve over the course of the rotation.
Please please be aware of sterile techniques in the OR. Anything with a blue drape on it is sterile and you cannot touch it unless you are scrubbed in wearing a sterile gown/gloves. Always protect your eyes with goggles or a face shield during the surgery if scrubbed in. Once you enter the OR doors (always cover your hair/ wear a surgical face mask/only wear surgical scrubs)
Ways you can be helpful as a medical student:
- Help move the patient from their bed to the OR table
- Take the bed out of the room
- Help put the SCDs on, bring a warm blanket for the patient at the beginning of the case as well as at the end of a case
- After the surgery, help anesthesia wheel the patient to recovery
- Place a foley before surgery if needed (ask a resident if they can show you how!)
- Ask the resident/ PA if you can help out before/after surgery
- If you are scrubbing into a surgery, introduce yourself to the OR staff and scrub tech. Pick out your sterile gloves ahead of time and hand the gloves to the scrub tech
- Practice suturing: consider purchasing a suture kit and practice during your down time; then offer to help close the patient at the end of the surgery
- During rounds, carry wound care supplies if needed (you can ask residents where to find these/which ones to have in your white coat pockets)
- Carry a pair of trauma shears to take down dressings (and on trauma rotation)
- Offer to perform post-op checks on your patients
- Pre-round on patients in the morning (chart check, write down labs too) and present to residents/attendings
Shelf advice: Studying for this exam was the most challenging in my opinion because of the long clinical hours of surgery. So the key is to be efficient! I highly recommend listening to Divine Intervention surgery podcasts during your drive to the hospital. He hits the high yield points that show up on the exam; one of his lectures comes with a powerpoint which can be found on his website and youtube. If you like Anki, use it during down time between OR procedures. Number 1 resource is UWorld. Practicing with questions is key–read the explanations well after each question, and come up with a method to review wrong answers, whether that is Anki or redo questions or writing out your wrongs in a notebook. If you like to read texts: DeVirgilo’s is a good book to reference. Pestana’s is a short read filled with high-yield points. Surgical recall is a great book to use to prepare for pimp questions. Emma Holliday also has an amazing review video+ slides on youtube! Online MedEd has helpful Free videos (if you are a visual learner). Pick 2-3 resources and stick with them during the rotation.
Surgery was my first shelf exam, and there were a lot of Internal medicine questions on the exam. If you completed Internal medicine before surgery, then the shelf will be more straightforward for you. That being said, if you have time, go over some internal medicine questions. However, there are over 1,200 medicine questions, so do not worry about completing all of them. Instead, you can review Divine Intervention’s Internal Medicine Shelf Review Lecture or Emma Holliday IM review.
The NBME website has 4 practice tests that are half the length of the real shelf exam. I would recommend doing these practice exams. They are good for learning how to tackle NBME style questions and get a score.
Resources:
- UWorld
- Practice NBMEs
- Divine Intervention Podcasts
- If you like textbooks: DeVirgilos, Pestanas, Surgical Recall
- Emma Holliday Review
- Online MedEd Videos
Internal Medicine
Clinical advice: In Internal medicine, you can be super involved as a student. Follow 2 patients each day with your intern. Try and learn as much as you can about your patient and know their HPI and medical/social history well. Present your patients on rounds to your attending or senior. This is the rotation to practice your oral presentation skills and learn to give concise, organized presentations. A great resource to help you look up diseases and develop management plans is UptoDate. Most hospitals should have a subscription to UptoDate. The book Step Up 2 Medicine lays out the basic diagnostic tests and management protocol for most disease processes. This can be helpful to formulate your assessment and plan for rounds/notes. Ask your seniors or interns for feedback on how to improve throughout the course of the rotations.
After rounds, offer to write notes on your patients (some hospitals count medical student notes for billing purposes); either way you will be writing notes on your patients for practice (whether the notes officially count or not).
If your patients are getting procedures done, ask if you can go along and observe (i.e. Interventional radiology, GI scope, Cardiac Cath procedures).
Clinical advice:
- Pre-round on your patients before formal rounds with your attending
- Write H&P/ progress notes on the patients you follow
- Offer to call the patient’s family and update the family on the diagnosis/ treatment plan
- Call consultants to discuss the plans for your patients
- Spend time in the afternoon explaining the diagnosis/treatment plan to the patient
- Update the nurses with the treatment plan
- Admit patients with your intern/resident
- Make a brief presentation about a topic relevant to your patient and present it to your team
- Help the nurses take vitals/move the patient/ etc.
- Attend noon conference with your residents (if required or if you are interested!)
Tips for the oral presentation (SOAP format):
- Opening Statement: ” 65 year old male with PMH of x,y, and z who presented with…” and the reason for why they are admitted “…currently admitted for management of cirrhosis.
- Overnight and interval events: “Yesterday, he had a therapeutic paracentesis and 4L of fluid was drained…” “No acute events overnight, this morning, the patient has altered mental status and improvement in abdominal pain. Patient only had 1 bowel movement yesterday. He was able to move from bed to chair with physical therapy and tolerated the clear liquid diet we started yesterday”
- Vitals: Determine if your attending wants the complete set of vitals or just wants an assessment of the vitals
- Ins and outs: “Total ins and outs” if relevant
- Physical Exam: Assess if your attending wants a focused physical exam or a complete exam
- Labs: Present relevant labs (e.g. hemoglobin stable at 8.5).
- Imaging: Any new imaging that was done in the last 24 hours
- Micro: Update on any cultures (e.g. blood cultures, no growth at 72 hours; urine is now growing E. coli).
- Pathology: If relevant
- Assessment: While you can start your assessment as “So, again, this is a 65 year old male who presented with altered mental status, abdominal pain, and distension admitted for management of cirrhosis. Patient currently still has Hepatic Encephalopathy, but improvement in abdominal distension since draining the ascites…” remember your assessment is your overall impression or feel of the patient. Are they improving? Is their current management helping them get better? What is causing this disease process? What elements of the clinical puzzle are missing?
- Plan: Organize your patient based on problems. Create a plan/rehash what the team is doing for each active problem a patient is dealing with in the hospital. For example; For Hepatic Encephalopathy→ Plan: Increase Lactulose to 30 g TID and Continue Rifaximin, goal number of bowel movements 3-4 per day
IM Shelf advice: UWorld, UWorld, and Uworld again….do all the questions for medicine if possible. This shelf exam will have concepts from other rotations, but doing all the IM questions will prepare you. Similar advice to surgery, use podcasts (Spoonful of Sugar and Divine Intervention) to learn content. If you like to refer to a text: Step Up 2 Medicine is a good reference. Pocket Medicine is a small book that fits in your white coat pocket and can also be a great reference to look up necessary diagnostic/management steps for various disease processes. Use Divine Intervention and Emma Holliday reviews to learn all the high-yield topics. Remember to do practice NBME exams.
Resources:
- UWorld
- Divine Intervention Podcasts
- Emma Holliday Review
- Online MedEd Videos
- Pocket Medicine
- If you like textbooks: Step Up 2 Medicine
- Practice NBMEs
Psychiatry
Clinical advice: Please see advice under Internal Medicine. Most of the clinical roles will be similar. Specific to Psych–offer to make ‘collateral’ calls, which is you call a family member to get more information about a patient’s presenting symptoms and how long they were dealing with the symptoms (i.e bipolar symptoms). You can ask about social and family history to get a better understanding of the diagnosis and treatment plan. Many patients might need a MOCA (memory test), so you could offer to conduct that. Attend group counseling sessions and work on interviewing psych patients. Learn the mental status exam well and know the timelines of the psych diseases/indications for medications well.
Shelf advice: This exam combines knowledge from Medicine, Neuro, and Psych. Become comfortable distinguishing Psychiatric conditions from Neuro conditions. Again, use UWorld as your primary resource. If you like textbooks: First Aid Psychiatry Clerkship is a great resource. Know the psych and neuro medications well for the shelf.
Resources:
- UWorld
- Divine Intervention Podcasts
- Online MedEd Videos
- First Aid: Psychiatry Clerkship
- Practice NBMEs
Neurology
Clinical advice: Similar to Internal Medicine. Follow 1-2 patients a day and present your patients to the team. Learning the Neuro physical exam is an important skill, and this rotation will help you feel comfortable in doing so!
Roles as a student:
- Keep a reflex hammer, tuning fork, and pen light in your pocket to help with the physical exam
- Learn how to do a thorough mental status exam and the full neuro physical exam
- If you have extra time, watch procedures, such as EEG and EMG
- Offer to speak with families or call consultants if needed
- Learn indications for different brain imaging and become comfortable looking at CT and MRI Head imaging
- Review your neuroanatomy and pathways
Shelf advice: This shelf combines knowledge from Neuro, Psych, and Medicine. The shelf may include basic CT Head non-contrast or MRI images, so become comfortable interpreting these imagings. UWorld will be your primary learning tool for the shelf. Review the psych and neuro medications well, including the side effects for each medication. Additionally, briefly review your neuroanatomy and pathways for the shelf.
Resources:
- UWorld
- Divine Intervention Podcasts
- Online MedEd Videos
- Practice NBMEs
Pediatrics
Clinical advice: Pre-rounds, rounds, conferences, and bedside teaching will be consistent with internal medicine’s format. Conducting a H&P on children and parents will be slightly different from internal medicine. If the patient is an infant, make sure to ask about pregnancy information and neonatal history. For all children, it is important to verify immunization history, developmental milestones, and environmental factors (who does the child live with at home, what grade in school, what does the child eat, how long does she sleep, behavior at home/school, etc.). It might be helpful to carry stickers or keychains to keep children occupied while you perform a physical exam.
Shelf advice: Review genetic diseases (remember the diseases from the biochem chapter in your First Aid Step 1 book), Review Developmental Milestones, Congenital Diseases..again UWorld, podcasts, NBME exams, Emma Holliday reviews, if you are looking for a text to accompany your studying, BRS Pediatrics or Case Files Pediatrics would be good resources.
Resources:
- UWorld
- Divine Intervention Podcasts
- Emma Holliday Reviews
- Online MedEd Videos
- Practice NBMEs
- BRS Pediatrics
Family Medicine
Clinical advice: This is the best rotation to learn about outpatient medicine. The rotation will help you become comfortable taking a thorough H&P, while learning how to be concise and work under limited time. Unless your attending or resident gives you more time, try to spend 10 minutes with your patients because your attending has to see the patient after you (so leave them enough time). Review management of chronic conditions (such as HTN, Diabetes, CKD, COPD, etc.). UpToDate will be your friend to review treatment plans for each disease. Additionally, know the USPSTF Group A guidelines well for screening and testing. Practice your physical exam skills, taking blood pressure, listening for heart and lung sounds, MSK maneuvers, etc. Ask your residents/attendings to teach you physical exam skills that you are not comfortable with. If your rotation has any inpatient weeks, please see the advice under the internal medicine rotation.
Shelf Advice: You can sign up for free family medicine practice questions at AAFP. As for the other rotations…use UWorld, Podcasts (Spoonful of Sugar and Divine Intervention), Memorize all the USPSTF Group A Screening guidelines. If you want a textbook to review: Case Files FM is a good resource. Don’t forget to complete NBME practice exams before the shelf!
Resources:
- UWorld
- AAFP Practice Questions/ USPSTF Screening guidelines (Group A)
- Divine Intervention Podcasts
- Online MedEd Videos
- Practice NBMEs
- Case Files Family Medicine
- Step Up to Medicine: Ambulatory Section
Ob/Gyn
Clinical advice: Introduce yourself to each patient and ask the patient if she is comfortable if you are present in the room. During this rotation, have some ultrasound gel packets, culture swabs, and a penlight available . The rotation will consist of labor and delivery floors, outpatient gyn, and a combination of gyn/onc & gyn surgery.
In Labor and Delivery triage, have an idea where the ultrasound machine is located, where used speculums go, where towels and gowns are stored. Introduce yourself to the mother hour(s) before the delivery. Close to the delivery time, gown and glove up and be present at bedside before the resident and attending arrive. If you display that you are prepared, you will likely participate in the delivery.
For gyn/gyn- onc surgery, refer to advice under the ‘Surgery Rotation.’ For outpatient gyn, learn how to perform a speculum exam. Remember to review the USPSTF screening guidelines for gyn. Familiarize yourself with different forms of birth control. Also know your pregnancy timeline and screening recommendations.
Shelf Advice: Along with UWorld questions and Divine Intervention Podcast reviews, for more practice questions complete ‘The APGO Undergraduate Web-Based Interactive Self-Evaluation (uWISE)’ questions. uWISE questions are extremely helpful for the shelf exam, and you can work on specific topics you may be weaker in. If you want a textbook to refer to during the rotation, CaseFiles ObGyn is a good resource. Know your pregnancy timeline and screening indications well.
Resources:
- UWorld
- UWISE Practice Questions/ USPSTF Screening guidelines (Group A) for Gyn
- Divine Intervention Podcasts
- Online MedEd Videos
- Practice NBMEs
- Case Files ObGyn
Spoonful of Sugar 