Here I am, over half-way finished with my third rotation and feeling like time has flown by. It feels like just yesterday I was prepping myself to start my first rotation! I had heard many stories of students on their first day of rotations, some good, some scary. One was about a girl starting out in pediatrics, and her preceptor says, “Hi, there is a kid in room 1 with a sore throat. Go take a look and then tell me what they’ve got.” This story terrified me just a little… ok maybe a lot. Don’t get me wrong, we had just spent a year stuffing our heads full of information and being tested on not just medicine but also the art of medicine. But that was all with fake patients in fake scenarios. This was the real deal! All of our professors told us we’d do fine and that it would be ok, but I was still VERY nervous.
First off: rotation basics. While there are national guidelines each PA program must abide by, each programs does the clinical year a little differently. We have 8 rotations of 6 wks: inpatient, surgery, family medicine, pediatrics, emergency, 2 electives, and a split behavioral health/women’s health. We also have several call back weeks between rotations where we spend time back at the Francis Center learning, presenting, and testing. We don’t all start out at the same rotation but are mixed up. Even if we are on the same rotation the experience is not the same. My inpatient experience at one hospital was vastly different than my classmate’s inpatient experience at another, due to the nature of being at different hospitals with different set ups and different preceptors. You are assigned a preceptor for your rotation. Usually this is the person that you will work with for the next 6 weeks. You follow their schedule, whatever it might be so your schedule can change drastically every 6 weeks. Your preceptor will grade you on things like medical knowledge, physical exam skills, ability to communicate with patients etc. It’s all based off a rubric (grading sheet) that they’re given, and which will account for the majority of your grade for that rotation. The rest of your grade is based off of your professionalism score (also graded by your preceptor) and your End of Rotation exam score (a national computer exam.) Sometimes your “preceptor” assigned to you is really a contact person and you may have several different medical providers you work with. You also get to log each patient you see on an online digital database (Typhon) as a way of documenting what you’re doing each day (more Typhon Tips later.)
My first rotation was my inpatient rotation. This means I was in a hospital working with patients that were admitted to the hospital for any reason. We had a variety of patients suffering a variety of problems from stroke to sepsis to congestive heart failure to COPD exacerbation and everything in between. The hospital I was at was also a teaching hospital so there were medical students as well as residents (in their first years after completing medical school). I worked on a team with several medical residents and we had a different attending physician every couple of days. My schedule was Mon-Fri 7am-7pm-ish. Each team was assigned a set of patients and then we were each assigned certain people from that list to take lead on. We would get “signout” first thing in the morning from the overnight team (an accounting of how the patients did, intro on any new patients, etc) and then would spend some time “computer rounding.” Computer rounding entailed us looking up each of the patients we were assigned on the computer. If it was a new patient we would get familiar with their case, write down their blood work/lab values, know what meds they were on and try to determine if they were receiving proper care or if any changes were needed. If it was an established patient we would look over their lab values etc and make sure no new problems had occurred and that they were getting treated appropriately. After looking up each patient we would then go to each patient’s room for “pre-rounding”. We’d spend some time with each patient talking over their care, making sure they were doing ok, and discussing any concerns they might have. We would then do a physical exam before moving on to our next patient.
After we had a chance to pre-round on the patient’s we were assigned lead, we would meet up with our attending physician and have rounds. The attending would call out a patient’s name and whoever had that patient was expected to present their case. The info to present varied slightly depending on which attending you had but it’s basically the highlights. Who the patient is, why they are in the hospital, what other conditions they might have that could cause difficulties, what treatment they were receiving, any abnormal lab values or changes in labs, any pertinent physical exam findings, and your recommendation on next step. We would take a few minutes to discuss the patient and make sure we were on the same page treatment and disposition wise. Some preceptors would take some time to “pimp” you, (or ask you specific questions about the patient, treatment choice, side effects of treatment, minutia about the disease, important diagnostic tests, etc.) so computer rounding and pre-rounding was very important. Depending on each attending we would then go see that patient as a team or we would finish rounding on all the patients on that floor before going to see them as a team.
This whole process usually took up the entire morning. In the afternoon, the residents would work on all the paperwork that medicine generates including progress notes, discharge summaries, transfer orders, etc. We’d check up on each patient and any labs that were re-drawn or imaging tests that were ordered. Throughout the day we might be notified that we were taking an admission. This meant that the ER doctor felt the patient needed to be admitted for further care. We’d go see and interview the patient and make sure any lab work or imaging needed had been ordered and that treatment was started.
I learned a lot on my inpatient rotation, especially about labs. How to read them, which were critical, which to treat, which to watch, and how to treat them. All based on correlation to the patient. NEVER treat a number. We also saw many patients with acute exacerbations of chronic conditions such as COPD, CHF, DM, a-fib, etc. We read many chest x-rays and EKGs. I was so excited when I was finally able to make the shadows or the squiggly lines mean something in my brain. I learned that there’s book medicine and then practical medicine. For example, one disease might have two first line treatments but if the hospital only caries one of those drugs you are only going to order that drug. I also learned to not forget the basics. Look at your patient and use your physical exam to help you diagnose and determine treatment efficacy.
Dos: I found the little orange book, Pocket Medicine the internal medicine edition to be very helpful for a quick resource guide. My hospital also had pre-made papers with empty lab value spots that I found very helpful in organizing my data and patients. Ask questions. To your residents if you have them. To your attending. To your nurses. Asking questions helps you learn and makes you look engaged. Ask to watch/do procedures. We learned how to insert catheters in the classroom but I wanted real life experience so I asked a nurse. She said sure and was very helpful with practical tips. I wanted to see an LP so they said call radiology. I did and they said come on down! So I did. Do study a little every day. Helps you retain more and makes the 200+ page study guide easier to deal with.
Don’ts: It is never good to space out when another person is presenting. It might not be your patient but you still might get pimped on it. It is never good to have a blank face and go “uhhhhh” when your attending turns to you. NEVER lie. If you don’t know, you don’t know. But if you make it up or guess they will find out and you will lose trust. (Tip given to me, NOT something I learned firsthand. 🙂 ) Don’t leave early often, you miss out on a lot. Some early evenings can be slow but you can get admits, have opportunities to do/watch procedures like central line placement, and more. And of course, the one time you leave early they’ll have a code you could’ve participated in.
In summary, you get out of your rotation what you want. YOU are in charge of your learning and education. Ask questions, ask to watch, ask to do, ask for feedback. You’ll never know if you don’t ask. The people you are working with know you’re a student and for the most part are ready and willing to help you learn and grow so don’t be afraid to open your mouth and to push yourself. In the words of one of my attendings, “if you’re not slightly uncomfortable or don’t feel stupid/baffled at least once a day, you’re not doing it right.”
And for those days you’re feeling especially baffled…