Order of core rotations

[tooty]

So we're ranking our preferred order of core rotations now. The major rotations we are dealing with are peds, surgery, and medicine. Of course, I'd like to do well in all my rotations, so which order is optimal?

 

I hear peds is a good rotation where I can see 'everything.' I can then go into the next rotation being better prepared. But I also think taking medicine first might serve the same purpose.

 

The 3 main tracks to choose from are:

 

1. peds--------surgery-----medicine-----etc.

2. medicine-----peds-------surgery-------etc.

3. surgery------medicine----peds---------etc.

 

Which one would be best? Obviously a bunch are going to say that it doesn't matter but I'm not very convinced of that.

[tooty]

Thanks brook. What's your opinion on peds vs. medicine rotations in terms of the the breadth of medicine they offer?

[Darla]

Thanks brook. What's your opinion on peds vs. medicine rotations in terms of the the breadth of medicine they offer?

 

Both offer a real breadth of medicine. Your pharm knowledge will be stronger with peds, your usual disease info with medicine.

 

The diseases seen in both are very different, 75 yo ladies don't present with duodenal atresia.

 

I started with medicine and thought it was perfect. IM folks are retentive and thorough which I liked to have under my belt bf hitting surgery when all the meticulous record keeping would go out the window.

 

To be honest though, starting with either would do you well. If you want to work with adults, starting with either medicine or peds is good (medicine b/c it lasts so much longer than peds).

 

If you want peds, starting with medicine may be useful b/c you'll have some background info and context to help you understand your whirlwind peds rotation.

 

Disjointed info, sorry, my caffeine hasn't kicked in yet

[tooty]

Ty

[boodog]

Ty

 

honestly, i would begin with surgery. i agree with the other posters advice to not begin with something you are interested in. surgeons don't expect much from you, becuase usually you aren't stuck with one preceptor but shuffled between several unlike the other rotations where they see you daily for up to 8wks of time. surgery you learn how the hospital works. it sucks balls in terms of the hours, but everything after that will appear like a joke, hours wise, not in terms of the amount of knowledge needed.

[Smurfette]

I REALLY don't think it matters. I know people who were interested in medicine who started with medicine and those who finished with it. Ditto for peds, surgery, etc. They're all in the same boat. The only issues are: if there are a few things you are "not sure about" then you might want to do them relatively early to rule in/out so that you can set up elective accordingly. That's the only thing that really matters. Some people say don't start with something you're interested in because you'll be too fresh and stupid, but honestly your staff know it's your first rotation and they're generally looking for nice people who are keen to learn. They'll judge you relative to where you are in your training. Plus starting with something you are interested in helps you rule it in/out and compare to other rotations. It's your electives that really matter in the end. And you'll be much more keen and less tired on your earlier rotations. By the end, you might be more seasoned but you'll likely also be more burnt out.

[leviathan]

I read a study online that med students do better on clerkship if they start with IM,. Probably doesn't make any real difference though.

[Lactic Folly]

Suggest doing an elective between 2nd and 3rd year to get your feet wet in the hospital system, and even out any possible disadvantage of your rotation schedule.

[tooty]

Suggest doing an elective between 2nd and 3rd year to get your feet wet in the hospital system, and even any possible disadvantage of your rotation schedule.

 

I plan on doing that. I'm glad someone else thinks it's a good idea

[DubZteR]

So we're ranking our preferred order of core rotations now. The major rotations we are dealing with are peds, surgery, and medicine. Of course, I'd like to do well in all my rotations, so which order is optimal?

 

I hear peds is a good rotation where I can see 'everything.' I can then go into the next rotation being better prepared. But I also think taking medicine first might serve the same purpose.

 

The 3 main tracks to choose from are:

 

1. peds--------surgery-----medicine-----etc.

2. medicine-----peds-------surgery-------etc.

3. surgery------medicine----peds---------etc.

 

Which one would be best? Obviously a bunch are going to say that it doesn't matter but I'm not very convinced of that.

 

Echoing what others have said about not starting with a rotation in a field that you think you might be interested in.

 

I started with IM cuz I couldn't see myself doing that and wanted to just get it over with! I then did gen surg cuz I thought I might as well be miserable in the winter time rather than the spring/summer when the weather is nicer. I also had to do take NBME shelf exams after each core, so the surgery shelf is really like a medicine shelf so even though I hated those exams with a passion, I was glad I had gotten the two hardest shelves out of the way !!!!

[DubZteR]

I REALLY don't think it matters. I know people who were interested in medicine who started with medicine and those who finished with it. Ditto for peds, surgery, etc. They're all in the same boat. The only issues are: if there are a few things you are "not sure about" then you might want to do them relatively early to rule in/out so that you can set up elective accordingly. That's the only thing that really matters. Some people say don't start with something you're interested in because you'll be too fresh and stupid, but honestly your staff know it's your first rotation and they're generally looking for nice people who are keen to learn. They'll judge you relative to where you are in your training. Plus starting with something you are interested in helps you rule it in/out and compare to other rotations. It's your electives that really matter in the end. And you'll be much more keen and less tired on your earlier rotations. By the end, you might be more seasoned but you'll likely also be more burnt out.

 

Staff will judge you relative to where you are in your training for example .. "you are a third year medical student" ... not "you are a third year medical student on their FIRST clinical rotation". The previous medical student that particular staff worked with before you may have been the seasoned third year med student in the class above you (now 4th year) who finished their last core. This same staff now has to work with you and thinks to themselves, wow that other third year med student knew so much more than this third year med student. Suddenly, the fact that you just started your very first clerkship EVER in medical school may become overlooked!

 

The point being, don't schedule a specialty that you think you'll want to do first. You'll spend the first week looking lost on the wards and that is no way to make a good lasting first impression on your potential future colleagues. Schedule it relatively early on (ie. 2nd/3rd block) but not first. Preclinical med students tend to have it set in their mind they'll love xyz specialty so they may just leave it towards the end, but the reality is often very different once they get a dose of xyz specialty. If you do xyz specialty and love it ... then great, you're laughing. However, if you end up hating xyz specialty, at least you've done yourself a huge favor by ruling it out fairly EARLY on so you can devote more time and energy to exploring and entertaining other specialties.

[Darla]

I'm not sure I agree DubZter. The preceptors I had in my first rotation knew that I was "brand new" and expected me to be really dumb. It didn't take much to impress them.

 

When the resident I was working with my first night of call (also my first day of clerkship ) didn't realise it was my first day and was ridiculously yucky, I told her it was my first day and that I would appreciate a bit of help and she was awesome from then on.

 

While it's true that not all preceptors care about what your stage of training is, you'll see that most do.

[DubZteR]

I'm not sure I agree DubZter. The preceptors I had in my first rotation knew that I was "brand new" and expected me to be really dumb. It didn't take much to impress them.

 

When the resident I was working with my first night of call (also my first day of clerkship ) didn't realise it was my first day and was ridiculously yucky, I told her it was my first day and that I would appreciate a bit of help and she was awesome from then on.

 

While it's true that not all preceptors care about what your stage of training is, you'll see that most do.

 

Darla,

 

I'm sorry to hear you were on call your very first day of clerkship but glad to hear you were on with a resident that was understanding of this. I'm not much for the mentality that you should just throw someone into the water and expect them to swim.

 

Agreed, it shouldn't take much to impress your staff on your very first rotation. During face to face interactions it may seem like they have accounted for your level of training (ie. by the difficulty of pimp questions they ask you) ... However, this doesn't change the fact that they have to evaluate you and write a narrative for you. When you're brand new on the wards, your knowledge base will be very subpar and whether or not your staff expect this of you or not ... it will show and staff will comment about your knowledge base on your evaluation and you may get feedback like "knowledge base good for first rotation", or "did well for first rotation". These are not bad comments but definitely would fall inferior of comments such as "knowledge base excellent for a third year" or "strong working knowledge of clinical medicine" had you done the same rotation later on.

[DubZteR]

Actually, Darla's account is on par with what my friends in the 2012 class have told me re: their first rotation. When we got the clerkship talk they also said that they have lower expectations for students in the beginning but these expectations rise as you progress through clerkship, regardless of the rotation. Maybe its a UWO thing.

 

The general consensus is that expectations are lower for students on their first clerkship. I'm not debating this point. My point is how this affects you and your evaluation. One of the points I raised is how your knowledge base will suck a$$ on your first rotation. You can approach it from any angle you want ... the reality is its hard for someone to give you the benefit of the doubt without stretching the truth about how much you really know. It's hard to get glowing reviews when your level of functioning as a clerk is generally regarded as subpar for the first several months of your clerkship year.

[Lactic Folly]

When you're brand new on the wards, your knowledge base will be very subpar and whether or not your staff expect this of you or not ... it will show and staff will comment about your knowledge base on your evaluation and you may get feedback like "knowledge base good for first rotation", or "did well for first rotation". These are not bad comments but definitely would fall inferior of comments such as "knowledge base excellent for a third year" or "strong working knowledge of clinical medicine" had you done the same rotation later on.

 

I'm not sure why one's knowledge base would be expected to be subpar when starting clerkship, given that this material is covered in the first two years of medical school. Clinical skills and formulating differentials/plans - sure. Also, some knowledge tends to be rotation dependent, and having started with psych or family may not help you very much when you are on surgery next.

 

I asked for and used a reference from my first rotation. Yes, they said my clinical skills were "evolving", but commented on the strength of my knowledge base and personal qualities. I used letters from later on in the year to confirm that my skills were indeed evolving appropriately.

[Lactic Folly]

When you're brand new on the wards, your knowledge base will be very subpar and whether or not your staff expect this of you or not ... it will show and staff will comment about your knowledge base on your evaluation and you may get feedback like "knowledge base good for first rotation", or "did well for first rotation". These are not bad comments but definitely would fall inferior of comments such as "knowledge base excellent for a third year" or "strong working knowledge of clinical medicine" had you done the same rotation later on.

 

I'm not sure why one's knowledge base would be expected to be subpar when starting clerkship, given that this material is covered in the first two years of medical school. Clinical skills and formulating differentials/plans - sure. Also, some knowledge tends to be rotation dependent, and having started with psych or family may not help you very much when you are on surgery next.

 

I asked for and used a reference from my first rotation. Yes, they said my clinical skills were "evolving", but commented on the strength of my knowledge base and personal qualities. The latter is something that people tend to pay close attention to - skills and knowledge can be attained through hard work, but it is much more difficult to remedy laziness and unprofessionalism. I used letters from later on in the year to confirm that my skills were indeed evolving appropriately.

[A-Stark]

I agree. My clinical and basic science knowledge wasn't "subpar" at the beginning of clerkship, but I'd never worked on a ward before much less been on call or put together admission orders or dictate discharge summaries. That was the learning curve, and it was tough going the first one or two times on call when all I'd been doing were clinics and the uselessness that was NICU. By the end of peds, I'd been more or less running the floor and unit myself for a whole week and triaging simultaneous emerg consults. It's actually kinda exciting to see your skills and competencies improve over time.

 

In any case, I definitely didn't find that the expectations were lower for completely green clerks. They probably shouldn't be, really, but I also do think that clerkship directors need to be more aware that how things get and should be done is better spelled out explicitly in detail at the beginning. (Ironically they gave me a lengthy orientation manual for my current rotation which is grossly in excess of the actual expectations placed on me.)

[DubZteR]

I'm not sure why one's knowledge base would be expected to be subpar when starting clerkship, given that this material is covered in the first two years of medical school. Clinical skills and formulating differentials/plans - sure. Also, some knowledge tends to be rotation dependent, and having started with psych or family may not help you very much when you are on surgery next.

 

I asked for and used a reference from my first rotation. Yes, they said my clinical skills were "evolving", but commented on the strength of my knowledge base and personal qualities. The latter is something that people tend to pay close attention to - skills and knowledge can be attained through hard work, but it is much more difficult to remedy laziness and unprofessionalism. I used letters from later on in the year to confirm that my skills were indeed evolving appropriately.

 

The first two years of medical school generally do not prepare students well for the wards. They are largely centered around learning the basic sciences and building one's basic science knowledge base. Little emphasis is placed on developing one's clinical knowledge base because the assumption is that this will be taught this in the clinical years. You acknowledged this in your post by referring to areas that tend to be deficient at the start of clerkship: lack of clinical skills, lack of ability to form a working differential and lack of ability to formulate a treatment plan. These are areas that most clinicians refer to when they use the term "knowledge base". Few clinicians in my experience, will comment on a student's basic science knowledge base in their clinical narratives.

 

Agreed, some knowledge tends to be rotation specific. However, regardless of rotation, there are valuable overlapping skill sets that third year medical students will need to learn, that will carry over and help them from rotation to rotation. Using your examples, doing inpatient pscyh, you could learn how to write admission orders. Doing family med, you could learn how to interpret basic lab values and basic radiologic imaging (ie normal vs. abnormal). By the time you start surgery, you will have three very valuable skill sets that you could easily adapt to surgery ... three skill sets that you would not have learned .... had you started with surgery.

[A-Stark]

I knew *how* to write admission orders but, obviously, I never had before. Otherwise clerkship is for learning about diagnosis and management in practice. Pre-clerkship clinical knowledge is about the Hx and Px. We aren't expected to know, starting off, what the indications for IVIG in ITP are or how to manage an incidental rectal ca intra-operatively.

 

And, yes, it was just me and the staff. It's not that impressive given that general peds inpatients are often stable and/or social/psych admissions but great experience nonetheless. I don't find understanding the rationale for investigations a "struggle" though. Always key to think about what you expect to find and/or rule out, and how with this information it might change the management.

[Lactic Folly]

The first two years of medical school generally do not prepare students well for the wards. They are largely centered around learning the basic sciences and building one's basic science knowledge base. Little emphasis is placed on developing one's clinical knowledge base because the assumption is that this will be taught this in the clinical years. You acknowledged this in your post by referring to areas that tend to be deficient at the start of clerkship: lack of clinical skills, lack of ability to form a working differential and lack of ability to formulate a treatment plan. These are areas that most clinicians refer to when they use the term "knowledge base". Few clinicians in my experience, will comment on a student's basic science knowledge base in their clinical narratives.

 

Agreed, some knowledge tends to be rotation specific. However, regardless of rotation, there are valuable overlapping skill sets that third year medical students will need to learn, that will carry over and help them from rotation to rotation. Using your examples, doing inpatient pscyh, you could learn how to write admission orders. Doing family med, you could learn how to interpret basic lab values and basic radiologic imaging (ie normal vs. abnormal). By the time you start surgery, you will have three very valuable skill sets that you could easily adapt to surgery ... three skill sets that you would not have learned .... had you started with surgery.

 

When I think of clinicians commenting on knowledge base, I think of the "pimp" questions that are asked on rounds, which are clinically focused but are not a direct test of clinical skills. Even if a student does not come up with a differential diagnosis in order of likelihood, when asked about one of those diagnoses, they should know the prevalence, risk factors, signs/symptoms, workup, management, and prognosis based on their preclerkship studies. I don't know how other schools structure their curriculum, but our preclerkship curriculum was quite clinically centered. Our respirology block started with anatomy and physiology, but the remaining lectures were talks such as "Approach to Hemoptysis.. Pulmonary Embolism.. Pneumothorax.. ABGs" and so forth. Basic science topics (such as is tested on the USMLE Step One) are likely emphasized to a greater extent in the US.

 

Yes, psych helped me practice my history/physical skills (though I never looked at an xray on urban family - was that just my clinic?). However, it has been my experience that the application of these skills varies widely, and the student needs to be adaptable to suit that particular rotation/site/preceptor, sometimes to the extent that it is almost a new skill. One's surgical AVSS NVI CCM will certainly not suffice as a progress note in medicine, and someone who is used to spending quality time with patients and their families on geriatrics had best learn to speed round on surgery.

[DubZteR]

I knew *how* to write admission orders but, obviously, I never had before. Otherwise clerkship is for learning about diagnosis and management in practice. Pre-clerkship clinical knowledge is about the Hx and Px. We aren't expected to know, starting off, what the indications for IVIG in ITP are or how to manage an incidental rectal ca intra-operatively.

 

And, yes, it was just me and the staff. It's not that impressive given that general peds inpatients are often stable and/or social/psych admissions but great experience nonetheless. I don't find understanding the rationale for investigations a "struggle" though. Always key to think about what you expect to find and/or rule out, and how with this information it might change the management.

 

That's good to hear you were comfortable with *how* to write admission orders prior to starting your clerkships. I've worked with many med students and most struggle with writing orders especially at the start of clerkships. I guess you're not most, if you know *how* to do something without actually having ever done it.

 

hmm ... now it's you and the staff running the show ... in your last post it was more or less just you running the floor and unit for a whole week and triaging simultaneous emerg consults. Big difference I'd say.

[DubZteR]

When I think of clinicians commenting on knowledge base, I think of the "pimp" questions that are asked on rounds, which are clinically focused but are not a direct test of clinical skills. Even if a student does not come up with a differential diagnosis in order of likelihood, when asked about one of those diagnoses, they should know the prevalence, risk factors, signs/symptoms, workup, management, and prognosis based on their preclerkship studies. I don't know how other schools structure their curriculum, but our preclerkship curriculum was quite clinically centered. Our respirology block started with anatomy and physiology, but the remaining lectures were talks such as "Approach to Hemoptysis.. Pulmonary Embolism.. Pneumothorax.. ABGs" and so forth. Basic science topics (such as is tested on the USMLE Step One) are likely emphasized to a greater extent in the US.

 

Yes, psych helped me practice my history/physical skills (though I never looked at an xray on urban family - was that just my clinic?). However, it has been my experience that the application of these skills varies widely, and the student needs to be adaptable to suit that particular rotation/site/preceptor, sometimes to the extent that it is almost a new skill. One's surgical AVSS NVI CCM will certainly not suffice as a progress note in medicine, and someone who is used to spending quality time with patients and their families on geriatrics had best learn to speed round on surgery.

 

A lot more comes to mind for me than just the pimp type of questions. I feel that it would be unreasonable even at the end of third year (let alone at the beginning), to expect them to know all of those things you listed. I'll agree to disagree with you on this one.

 

I agree with you that the student needs to be adaptable but my original point is that there are skills these students could benefit from by being on family and psych that would carry over and help them on surgery ... (in response to your original comment about knowledge being rotation dependent, and perhaps not carrying over on the next rotation)

[lostintime]

That's good to hear you were comfortable with *how* to write admission orders prior to starting your clerkships. I've worked with many med students and most struggle with writing orders especially at the start of clerkships. I guess you're not most, if you know *how* to do something without actually having ever done it.

 

hmm ... now it's you and the staff running the show ... in your last post it was more or less just you running the floor and unit for a whole week and triaging simultaneous emerg consults. Big difference I'd say.

 

Whoa what clerk is allowed to run a floor? I mean, most clerks can't even sign orders themselves.

[Lactic Folly]

A lot more comes to mind for me than just the pimp type of questions. I feel that it would be unreasonable even at the end of third year (let alone at the beginning), to expect them to know all of those things you listed. I'll agree to disagree with you on this one.

 

I agree with you that the student needs to be adaptable but my original point is that there are skills these students could benefit from by being on family and psych that would carry over and help them on surgery ... (in response to your original comment about knowledge being rotation dependent, and perhaps not carrying over on the next rotation)

 

I may be extrapolating from my own experience. Even though surgery and OB were some of my last rotations in 3rd year, I did not find my previous rotations in psych/family to be of significant help in learning OR practices and surgery-specific orders, compared to doing pediatrics after internal medicine, where there seemed to be more overlap in ways of doing things.

 

Again from my own experience, I remember being asked about the indications for lumpectomy versus mastectomy while assisting in surgery, and being asked why we put ascitic patients on antibiotic prophylaxis (and what antibiotics are used) during medicine rounds. Now I don't know what was expected in terms of an answer from a 3rd year clerk, and certainly I would forget this information if not used, but I did get the impression that preceptors expected clerks to be reading and reviewing information from that specialty during each rotation (so knowledge would be fresh during that rotation, if not necessarily at the beginning or end of 3rd year).

[A-Stark]

That's good to hear you were comfortable with *how* to write admission orders prior to starting your clerkships. I've worked with many med students and most struggle with writing orders especially at the start of clerkships. I guess you're not most, if you know *how* to do something without actually having ever done it.

 

Well, they teach us to do it, starting with the "ADDAVID" mnemonic. We do practice dictations too.

 

hmm ... now it's you and the staff running the show ... in your last post it was more or less just you running the floor and unit for a whole week and triaging simultaneous emerg consults. Big difference I'd say.

 

I was the only housestaff there during the day, so I prerounded on my own, later with the staff, and then continued work over the day. As you said, not an especially acute set of patients, all of whom were stable. And in Saint John, clerks only can't give verbal orders. Written orders are electronic.