Is it a red flag if you don't get a LOR from an elective?

[confusedmedstudent]

I just did an elective where I had 2 preceptors (one week with each). I asked the 2nd one for a letter of reference because she gave me very positive feedback and said I was doing really well for someone at my level (I'm at a 3yr school so have electives before any core rotations sadly... just started clerkship in Jan) and was great to work with etc etc. She said that she thinks I am doing great and that when I go on my core rotation I'll be functioning at the level of a resident, and that she could write me a good but not great letter because we didn't work together much and also because she thinks I'm too early to truly evaluate my skills. What does this mean? Does she secretly think I suck??? 

I REALLY want to go to this program and unfortunately this early elective was the only one I could get there because of my schedule. It's my home school but I'm at a satellite campus and will have my core rotation there instead so I won't be working with her again. Is it a huge red flag if I apply here, having done an elective but no letter from the elective, even if I have a really strong letter from my core rotation?

Also any tips for getting letters

[1029384756md]

She already said she won't write a great letter, I wouldn't bother asking her for a letter. See if you can get another elective at this site last minute as the year goes on.

[bearded frog]

30 minutes ago, confusedmedstudent said:

I just did an elective where I had 2 preceptors (one week with each). I asked the 2nd one for a letter of reference because she gave me very positive feedback and said I was doing really well for someone at my level (I'm at a 3yr school so have electives before any core rotations sadly... just started clerkship in Jan) and was great to work with etc etc. She said that she thinks I am doing great and that when I go on my core rotation I'll be functioning at the level of a resident, and that she could write me a good but not great letter because we didn't work together much and also because she thinks I'm too early to truly evaluate my skills. What does this mean? Does she secretly think I suck??? 

I REALLY want to go to this program and unfortunately this early elective was the only one I could get there because of my schedule. It's my home school but I'm at a satellite campus and will have my core rotation there instead so I won't be working with her again. Is it a huge red flag if I apply here, having done an elective but no letter from the elective, even if I have a really strong letter from my core rotation?

Also any tips for getting letters

If it's your home program, then its fine. Get a letter from your core at your own site, and other electives. When it comes time to it, if it comes up in interview you can say you were only able to do an early pre-core elctive and Dr. X was impressed with my performance.

[ellorie]

I doubt it would be a red flag - probably if it's a smaller program and your application was strong otherwise, someone would look who your supervisor was and ask them about you if they were concerned about it.  Obviously it's better to have a strong letter from a supervisor there, but I wouldn't think it's the end of the world unless it's an ultra competitive program.  There's a lot of word of mouth that happens, especially since it's your home program.  It would be more of an issue if the supervisor actively disliked you.  That happened to me in Calgary and I'm pretty sure I got blackballed, but I think that would have happened whether or not I had used the letter (still shouldn't have used it though).  Luckily I didn't much want to match there anyway and the feeling was pretty mutual by the end of a truly terrible two weeks.

If you had a generally good relationship with this supervisor, you could also say to her that you understand why she would not be able to write you a great letter, but that you are hoping to match to the program, and would she have any recommendations about other things you could do to strengthen your application and show interest.

With letters, it can be helpful to say at the beginning that you are hoping for a letter and ask what you would need to do for that to be possible - some supervisors will then try to increase your time with one person, or all talk together to compile a letter.

[NLengr]

Personally if someone says they can't write a great letter, I wouldnt get one. That's them diplomatically saying they don't want to write one. 

[Intrepid86]

In almost every case where a preceptor provides an LOR after only one week with a student, it's because the student asked for one, not because the Attending wanted to give it. One week is not enough time to meaningfully evaluate someone, and those who think it is are fooling themselves. It doesn't necessarily mean you suck. It also doesn't mean the preceptor has high standards, is lazy, or being difficult. I would say not getting an LOR after just one week is not only normal, but expected. I would also say it's better to not have an LOR at all, rather than one which is weak or even average.

[JohnGrisham]

10 minutes ago, Intrepid86 said:

In almost every case where a preceptor provides an LOR after only one week with a student, it's because the student asked for one, not because the Attending wanted to give it. One week is not enough time to meaningfully evaluate someone, and those who think it is are fooling themselves. It doesn't necessarily mean you suck. It also doesn't mean the preceptor has high standards, is lazy, or being difficult. I would say not getting an LOR after just one week is not only normal, but expected. I would also say it's better to not have an LOR at all, rather than one which is weak or even average.

Agreed.

That said, it *IS* possible.   I received my best LOR from a preceptor when i was at that point, that I only worked with a week (same situation, 2 diff preceptors on a team-based service for 2 weeks). That LOR was without a doubt much better than ones where I worked with a preceptor for 3-4 weeks - because they actually took the time to sit me down and give my extensive feedback at the end of the week, before they offered me the LOR. It helped that the residents I worked with all went to bat as well.    

Backup LORs are better than being at the end of your electives with not enough letters. It happens to people, and its a struggle reaching out for LORs from sources that are less than ideal.  One 4 week rotation, I thought "great, I'll have a lot of 1:1 time and this will be the best LOR" and it was a flop - preceptor was away for 1 week, so I was with a locum, then he had a mixed schedule that meant i didn't always work with him. Lots of unpredictable variables - still got an LOR, but likely not as strong and minimal feedback at end of rotation or on official university documentation etc.

 

[hopeful_med]

It happened to me. I had an early elective in a specialty at home school I wanted, couldnt get a very strong letter because I was shuffled between two sites and never had a consistent preceptor. They asked about it in CaRMS why I didn't have a letter from my home school, explained the situation. I matched to my home program in that specialty, so as long as there is a good explaination I don't think it matters

[confusedmedstudent]

Thanks for the replies everyone. I'm very relieved to know that this isn't such a big deal!! Is that also true for semi-competitive programs? 

Also, I am trying to decipher my preceptor's feedback. She said I'm doing great for my level but she knows I'm going to get even better. Basically is she saying that I need to read more and have a better knowledge base in order to be competitive? I'm worried because I don't have a great memory and sometimes I'll read about a topic and when I'm asked about it the next day I remember very little of what I learned, even though I understood it the day before when I learned it. :/ I really only remember things long-term if I've seen them in a clinical context, which is unfortunate because I haven't done my cores yet so I don't know a lot of things. Everyone told me that it doesn't matter how much you know as long as you are a good person to work with and willing to learn... but I think I'm just not impressive with my knowledge, right? That's the problem?

Also she said that the next step for me to improve is that I should always come up with a differential and defend it and say what I think the problem is, but that feels highly highly inappropriate in our setting because the patient is there when the team rounds and I feel like it's so wrong to just be like "um this could be malignancy" in front of a patient. and I guess I could have spoken with the resident/attending about my DDx before rounds, but they are super busy all day and it also feels inappropriate to annoy them just to be like "hi this patient i saw, i think they have ____" Is this just the way it is? How do you navigate this?

 

 

[confusedmedstudent]

3 hours ago, hopeful_med said:

It happened to me. I had an early elective in a specialty at home school I wanted, couldnt get a very strong letter because I was shuffled between two sites and never had a consistent preceptor. They asked about it in CaRMS why I didn't have a letter from my home school, explained the situation. I matched to my home program in that specialty, so as long as there is a good explaination I don't think it matters

this brings me such peace thank you so much lol 

and congrats, i am so glad you got your top choice!!!

[Monkey D. Luffy]

Don't worry too much about it - if you get a letter from your core at the satellite site, I think you will be fine. People know each other and talk behind the scenes all the time.

[bearded frog]

18 hours ago, confusedmedstudent said:

Also, I am trying to decipher my preceptor's feedback. She said I'm doing great for my level but she knows I'm going to get even better.

I mean we can't answer this for you without seeing your evaluations but like knowing specific information about medical conditions is usually not a problem. Even my staff looks up treatment/diagnosis on uptodate all the time. She's probably saying you're doing great for the start of clerkship, but you learn so much just general medicine management stuff throughout clerkship, like increasingly efficient history and physicals, the basic management of common problems, writing notes, finding relevant information to come up with a differential/plan, presenting a patient, proposing plans, when to reassess, when you notify your resident/staff, logistical planning, etc. Stuff you can't study for necessarily that just comes from experience, and everyone knows it just comes from experience, so she's not judging you for it.

18 hours ago, confusedmedstudent said:

Also she said that the next step for me to improve is that I should always come up with a differential and defend it and say what I think the problem is...

This is also an important learned skill, combined with the even more difficult skill of discussing assessments and plans in front of patients, which you wont master until the end of residency, or even as a staff, and some staff are terrible at this. Coming up with a differential is very important and I always review this with my clerks before they present to staff. It sounds dumb sometimes because "this child obviously has bronchiolitis why am I wasting everyone's time by suggesting foreign body aspiration" but the point is that as a learner the staff has no idea what your thought process is, but if you say "based on the history and my physical assessment of a URTI followed by wheeze and respiratory distress by most likely diagnosis is bronchiolitis. Also on the differential is foreign body aspiration but the non-acute nature and viral prodrome make this less likely. There could also be a bacterial pneumonia but as the patient has no fever and has no focal findings on auscultation this is also less likely. Finally this could be first presentation of asthma but as the child is very young and there is no atopy on family history this is also less likely. I would therefore like to treat as bronciolitis" then they know you have at least done some reading and have considered these options, and if you suggest a management for your number one differential based on this then you will look very good even if they decide to do something else.

In terms of discussing assessments and plans in front of patients/families, this is very difficult to do well. Theoretically when you are doing your history and physical on the patient you are describing the results of your assessment at the same time, so at least your assessment findings should not come as a surprise. In terms of a differential, if your most likely diagnosis is cancer or something sensitive you need to mention this to your resident/staff prior to bedside rounds. Even now we try to do bedside rounds but if there is something that should be discussed prior I will tell my staff and we will discuss this prior to going into the patient room. Also avoid jargon. In front of the patient you would say something like "Based on Mrs. Jones's frequent abdominal pain and new presentation of hematochezia blood in her stool, there are a number of potential causes that require further assessment. Most likely is diverticulitis based on the localization of pain to the left lower quadrant of her abdomen, but we also need to consider inflammatory bowel disease based on her family history. Although unlikely, we cannot be completely certain that these symptoms are not caused by a more serious condition such as colon cancer, and should test for this as well". The idea being you qualify everything you say instead of just listing them out. Even if you think colon cancer is high on the differential, you would still start off saying things like "The most common reason for these findings is diverticulitis, but based on her history of weight loss, myalgias, etc as well as her strong family history of colon cancer I think it's important that we consider this diagnosis and investigate appropriately."

[confusedmedstudent]

On 2/16/2020 at 1:07 PM, bearded frog said:

I mean we can't answer this for you without seeing your evaluations but like knowing specific information about medical conditions is usually not a problem. Even my staff looks up treatment/diagnosis on uptodate all the time. She's probably saying you're doing great for the start of clerkship, but you learn so much just general medicine management stuff throughout clerkship, like increasingly efficient history and physicals, the basic management of common problems, writing notes, finding relevant information to come up with a differential/plan, presenting a patient, proposing plans, when to reassess, when you notify your resident/staff, logistical planning, etc. Stuff you can't study for necessarily that just comes from experience, and everyone knows it just comes from experience, so she's not judging you for it.

This is also an important learned skill, combined with the even more difficult skill of discussing assessments and plans in front of patients, which you wont master until the end of residency, or even as a staff, and some staff are terrible at this. Coming up with a differential is very important and I always review this with my clerks before they present to staff. It sounds dumb sometimes because "this child obviously has bronchiolitis why am I wasting everyone's time by suggesting foreign body aspiration" but the point is that as a learner the staff has no idea what your thought process is, but if you say "based on the history and my physical assessment of a URTI followed by wheeze and respiratory distress by most likely diagnosis is bronchiolitis. Also on the differential is foreign body aspiration but the non-acute nature and viral prodrome make this less likely. There could also be a bacterial pneumonia but as the patient has no fever and has no focal findings on auscultation this is also less likely. Finally this could be first presentation of asthma but as the child is very young and there is no atopy on family history this is also less likely. I would therefore like to treat as bronciolitis" then they know you have at least done some reading and have considered these options, and if you suggest a management for your number one differential based on this then you will look very good even if they decide to do something else.

In terms of discussing assessments and plans in front of patients/families, this is very difficult to do well. Theoretically when you are doing your history and physical on the patient you are describing the results of your assessment at the same time, so at least your assessment findings should not come as a surprise. In terms of a differential, if your most likely diagnosis is cancer or something sensitive you need to mention this to your resident/staff prior to bedside rounds. Even now we try to do bedside rounds but if there is something that should be discussed prior I will tell my staff and we will discuss this prior to going into the patient room. Also avoid jargon. In front of the patient you would say something like "Based on Mrs. Jones's frequent abdominal pain and new presentation of hematochezia blood in her stool, there are a number of potential causes that require further assessment. Most likely is diverticulitis based on the localization of pain to the left lower quadrant of her abdomen, but we also need to consider inflammatory bowel disease based on her family history. Although unlikely, we cannot be completely certain that these symptoms are not caused by a more serious condition such as colon cancer, and should test for this as well". The idea being you qualify everything you say instead of just listing them out. Even if you think colon cancer is high on the differential, you would still start off saying things like "The most common reason for these findings is diverticulitis, but based on her history of weight loss, myalgias, etc as well as her strong family history of colon cancer I think it's important that we consider this diagnosis and investigate appropriately."

Thank you so much for this, it's really helpful! I definitely need to be more intentional about making sure my preceptors know my thought process. Also I've gotten feedback from other preceptors that I need to take more focused histories and physicals which worries me because I am pretty sure my classmates already do this, they're all getting feedback saying that they function at R1 level (so I am probably already behind) and I'm always so scared of missing something that I do too much. 

Is it really bad if most of my letters are from cores rather than electives? (Especially for some programs that ask for 5 letters) because I do have some preceptors from early electives who agreed to write letters but I'm a very weak clerk at this point and I worry that they won't be able to say much about me except that I was nice to work with. I haven't had my core rotations yet and my electives will be done in like 2 months... I think I'll get stronger letters on cores but am worried it'll be bad not to have any from electives

[ellorie]

I would take that with a grain of salt. If it was normal for all CC3s to be functioning at the level of R1s there would be no point doing a clerkship. 

When I’ve supervised clerks very few function at the R1 level and most are exactly where you are in terms of struggling to get focused and oscillating between being over inclusive and leaving things out  

The best way to get better is to get direct observation followed by specific feedback. So get a staff or resident to watch your interviews, exams, and presentations and give you feedback on exactly where you could have condensed/focused more etc. And also observe staff and residents when you get a chance and ask them questions (later/if they have time) about why they focused where they did/left certain things out/had a particular thought process. 
 

I always tell my clerks, get good and then get fast. It’s normal when you are starting to take too long and get too much information. It’s actually good to be thorough until you are skilled enough to know what you can safely leave out.  Totally developmentally normal. 
 

FWIW I got good in PGY2-3 and got fast in PGY3-4. There’s a reason our training is so long. 

[confusedmedstudent]

24 minutes ago, ellorie said:

I would take that with a grain of salt. If it was normal for all CC3s to be functioning at the level of R1s there would be no point doing a clerkship. 

When I’ve supervised clerks very few function at the R1 level and most are exactly where you are in terms of struggling to get focused and oscillating between being over inclusive and leaving things out  

The best way to get better is to get direct observation followed by specific feedback. So get a staff or resident to watch your interviews, exams, and presentations and give you feedback on exactly where you could have condensed/focused more etc. And also observe staff and residents when you get a chance and ask them questions (later/if they have time) about why they focused where they did/left certain things out/had a particular thought process. 
 

I always tell my clerks, get good and then get fast. It’s normal when you are starting to take too long and get too much information. It’s actually good to be thorough until you are skilled enough to know what you can safely leave out.  Totally developmentally normal. 
 

FWIW I got good in PGY2-3 and got fast in PGY3-4. There’s a reason our training is so long. 

thank you for this, that is really reassuring! i'm just really worried that i'm behind because this is the feedback my preceptor gave me (that my histories/physicals aren't focused yet, and that i should present a ddx and say what i think the problem is + initial management), and i was thinking maybe she isn't comfortable writing a letter for me because i am behind for my level. also in general, to get a strong letter do you need to be operating above your level? i'm really not sure how i would do that :/

[confusedmedstudent]

Also is it bad if most of my letters are from my home school? I have most of my electives before my cores and I feel that I'll be stronger on core and probably get better letters. But will this look bad when I apply to other schools? Especially since my cores are at a satellite site and not an academic center?

[bearded frog]

14 hours ago, confusedmedstudent said:

 Also I've gotten feedback from other preceptors that I need to take more focused histories and physicals which worries me because I am pretty sure my classmates already do this, they're all getting feedback saying that they function at R1 level (so I am probably already behind) and I'm always so scared of missing something that I do too much.

In my experience a focused history and physical means two things: it's efficient and you ask specific presentation and diagnosis relevant questions as part of it. As a med student you are still expected to do a "complete" history and physical for general specialties, and even as a senior resident I still (and am expected to) ask screening development questions on every child I see. Efficiency comes with practice, for instance you can do a screening examination of an infant in about a minute, all while im taking a history, and being flexible so as not to annoy patient/family. It takes a LOT of practice but you get there. The idea of a "focused" assessment is that you are not just using all the default questions you learned in med school but are tailoring your questions to your differential as you do your assessment. For instance in a respiratory distress case with asthma is on the differential, I'm asking specifically about previous puffer use, episodes of wheeze, nighttime cough, exercise tolerance, history of allergies and eczema, family history of asthma, allergies, and eczema, smoking in the home, pets at home, previous flooding/mold risk in their home, proximity to factories, etc. When I review with med students prior to reviewing with staff, I have them go back and ask these questions so that when their reviewing with staff and saying these are all negative, and therefore you can be confident that asthma is unlikely. This is extrapolated to anything, I recommend taking two minutes to look up the differential on a patients presentation prior to assessing them (if it's appropriate to do so, IE physically look at the patient to ensure their not in distress, but this is more your senior's job to not assign a medical student to an unstable patient).

14 hours ago, confusedmedstudent said:

Is it really bad if most of my letters are from cores rather than electives?

The best letters are the best letters, regardless of the source. In an ideal world if you want to go to a specific program you will do a late elective there and ask for a supportive letter and work your butt off, but its better to have great letters from your home program then mediocre ones from all over the place. I would still talk to your preceptors on electives and explain that while its early in clerkship this is the only electives you will have so if they mind pushing you a little bit in order to write an effective letter, considering the early context. And hopefully when you apply programs will understand that your electives were early and consider that appropriately.

[rogerroger]

I do file review and write CaRMS letters. 
 

Only use references that will write you a strong letter. Treat this as a black and white matter. There are strong letters. Then there are weak letters. In reality an okay letter is useless. It tells the reviewer nothing. 
 

It’s not a red flag to have an elective without a letter. It’s actually common. 
 

Preceptors and file reviews know how hard it can be to have truly longitudinal experiences with a trainee. I mean, it wasn’t any different when we were in your shoes. We get it. I would say it is a red flag if a preceptor is claiming they didn’t work with you enough to write a letter. This probably is a way of saying, “I didn’t see you perform consistently to a standard where I can comment on your candidacy in a strong manner.” The exception to this may be if you only worked with someone for a few days. Then truly they might just have no idea who you are. Probably some speciality specific differences here in terms of how long is “long enough”. 
 

In all the letters I write I always start the letter by providing context. I explain who I am and how long I observed the trainee. I also usually attempt to quantify where they stand amongst the learners I’ve supervised. So for example;

I’m Dr. X, academic staff at Y. I supervise about K trainees a month. I worked with Mr. Smith over Q days, he is within the top Z% of students I supervised. 

This is common within letters. So keep this in mind when asking. 

You don’t want a letter that says they worked with you for two days and you are in the “top 75%” of students they worked with, or performing “as expected” compared to peers. Catch my drift? Not helpful to the file reviewer. Useless at best, harmful at worst. 

Edited February 18, 2020 by rogerroger

[iFlayx]

On 2/15/2020 at 2:18 PM, Intrepid86 said:

In almost every case where a preceptor provides an LOR after only one week with a student, it's because the student asked for one, not because the Attending wanted to give it. One week is not enough time to meaningfully evaluate someone, and those who think it is are fooling themselves. It doesn't necessarily mean you suck. It also doesn't mean the preceptor has high standards, is lazy, or being difficult. I would say not getting an LOR after just one week is not only normal, but expected. I would also say it's better to not have an LOR at all, rather than one which is weak or even average.

Is this true though? There are so many electives where you won't be spending 100% of the time with one preceptor and are often split with multiple. Given the new 8 week cap many people are also doing less weeks per elective in order to visit more programs and schools

[rogerroger]

2 hours ago, iFlayx said:

Is this true though? There are so many electives where you won't be spending 100% of the time with one preceptor and are often split with multiple. Given the new 8 week cap many people are also doing less weeks per elective in order to visit more programs and schools

Not true. At least for me. 

I can get a pretty good gist of a learner if working one on one with them for about 32-48hrs. So about 4-7 work days. 
 

I certainly write letters every year for students who worked with me for this amount of time. Beyond this time I really could only comment on their growth and learning over time. By this time I have seen what I need to see to give a description of their abilities in a snap shot moment in time. 

[confusedmedstudent]

@rogerroger thank you so much for your input, that is really helpful and reassuring. But I'm concerned that I'm really not performing above my level - preceptors say that I am "right where I should be" in terms of my skills but they have very positive things to say about my work ethic, willingness to learn, professionalism, being nice to work with etc. Are they just saying that so they can give me SOME good feedback? Since I am really not that good of a clerk in terms of my knowledge and skills? And if I'm not in the top 10% or whatever and my preceptors cant comment on that, is that really terrible in terms of my application? I hope not because not everyone can be top 10%... ? And what even constitutes top 10% - I'm not sure how to get there.

Also, some preceptors have agreed to write me a letter (from early electives - my first 4 weeks of clerkship) but now I'm worried that they won't be very strong because of how early I was and also because one preceptor I barely did anything with (the resident gave her feedback and she agreed to write based on that). Should I even bother following up with them to write these letters or will they be weak?

My last elective yielded no letter and my current one probably won't either just because of how it's set up (and because I suck haha it's a subspecialty and I know only the basics). So I think most of my letters will come from cores. Is that still ok? 

Sorry for all the questions. I appreciate all of your help!

[bearded frog]

12 hours ago, confusedmedstudent said:

@rogerroger thank you so much for your input, that is really helpful and reassuring. But I'm concerned that I'm really not performing above my level - preceptors say that I am "right where I should be" in terms of my skills but they have very positive things to say about my work ethic, willingness to learn, professionalism, being nice to work with etc. Are they just saying that so they can give me SOME good feedback? Since I am really not that good of a clerk in terms of my knowledge and skills? And if I'm not in the top 10% or whatever and my preceptors cant comment on that, is that really terrible in terms of my application? I hope not because not everyone can be top 10%... ? And what even constitutes top 10% - I'm not sure how to get there.

You can't do much other than read as much as possible, offer to do as much as possible, and stay late if possible etc. to try and demonstrate yourself. If you're doing the best you can, then you can't really worry about where you stand. You are who you are, can't change much about that now other than study up on cases, look engaged and interested, try and go the extra mile, etc.

12 hours ago, confusedmedstudent said:

Also, some preceptors have agreed to write me a letter (from early electives - my first 4 weeks of clerkship) but now I'm worried that they won't be very strong because of how early I was and also because one preceptor I barely did anything with (the resident gave her feedback and she agreed to write based on that). Should I even bother following up with them to write these letters or will they be weak?

When it comes time, follow up with them and say you appreciate the time you were able to spend with them at the start of your clerkship, and you would appreciate if they could write you a strong reference letter to support your residency application in that specialty, but that you also understand if they cannot, as it was early in clerkship and you've progressed a lot since then. This will hopefully give them the opening to say if they could write you a letter but not a strong one, and that way you can thank them anyway and not risk using a mediocre letter.

[confusedmedstudent]

@bearded frog thank you again for your help! I appreciate it. I really wish I knew what was clinically important in preclerkship so I could have spent time studying more high yield things and could be more knowledgeable now is it really bad if you're not super knowledgeable? Like even if I am very eager to learn and work hard and am nice, will my lack of knowledge on the early pre-core electives be a huge issue in terms of being a good candidate? And is it very important that preceptors write in your letter that you were in the top X%?

 

 

[confusedmedstudent]

Also if you meet with a program director what are you even supposed to say/is this important to do? Is it ok to ask what they look for in candidates when ranking?

[bearded frog]

16 hours ago, confusedmedstudent said:

 is it really bad if you're not super knowledgeable?

It doesn't matter if you don't know specific facts about conditions diagnoses, etc. that you can easily look up, with the expectation that you do so when you need to. Obviously once you see a case of X you should read about it "read around cases" so that the next day you can demonstrate that you can appropriately source info. The knowledge that we are looking for is how to appropriately act and assess patients, how to interact with nurses and allied health and colleagues, when and where to find accurate and appropriate information to guide your practice, stuff you can't just google or look up on pubmed/uptodate. When I have med students or even elective students I will ask them a question about a specific question or disease with the assumption that they don't know the answer, and that is 100% ok and you are not expected to know unless we already discussed it, but then I work backwards through the question and try to get them to come up with the answer on their own, based on the basic physiology/anatomy, etc. Stuff like "should we order a NPS on this child with likely viral triggered asthma". The answer is usually no, but its a difficult question to answer, so my next question is what is a nasopharyngeal swab, and if i don't know that I explain it, then I ask how the result would affect their management, if it was negative, vs flu, vs other virus, etc. And usually they can work through it and the point is to demonstrate their problem solving/reasoning skills.

16 hours ago, confusedmedstudent said:

And is it very important that preceptors write in your letter that you were in the top X%?

I can't answer this as I haven't been involved with reviewing LORs.

11 hours ago, confusedmedstudent said:

Also if you meet with a program director what are you even supposed to say/is this important to do? Is it ok to ask what they look for in candidates when ranking?

Ask about their program? At some point you will have to make a rank order list and decide which programs you will prioritize, so you should ask questions that would help you make that ranking. Don't ask specifically about ranking, but you can ask things like "What kind of applicants does the program look for" or "what kind of applicant would excel in this program" etc.