returning to clinics student advice
Student-to-Student Advice from the Mudphud Class of 2013
We (members of the MD-PhD class of 2013, building on the work of prior classes) surveyed Penn MuDPhuDs who returned to the clinics and survived! We have provided below their answers to the most frequently asked questions.
(Note: everyone is different, and though there are common themes in this advice, no one strategy works for everyone. Pick and choose as you will, and seek advice liberally!)
1. What general advice do you have for someone returning to the clinics?
- A lot of surviving in the clinics is about knowing how to navigate the hospital and the various sources of medical information. Knowing how to find patient information on Medview / Sunrise / EPIC / etc will be much more valuable at first than any actual medical knowledge. Take a minute to review some of those tools (if you remember your passwords) during MED250 if you can and you will be way ahead of the curve.
- RELAX! Most people said that they were much more worried than they needed to be and the transition was a lot smoother than expected. The medical class you are rejoining does not know as much as you think they do. Most people felt they actually knew more “practical” stuff about being in the clinic (what to do, where to find information) than the class they rejoined. But in the end, we ALL get lost in the hospital and don't know stuff. So don't feel too anxious.
- Make sure to check all the boxes. There are a lot of “little” things you need to do while returning that can be annoying to take care of when you are already back on a service. The "getting back to clinics" list that you should have received from Maria Hernandez or Helene Weinberg should be followed religiously. Keep a copy of your PPD clearance so you can get a Presby ID if you need one. Try and remember your sunrise / medview / epic logons and call and reset them if you don’t. Remember to schedule the sunrise and epic training early (it can take forever to do)
- Definitely let people know you are a returning PhD. It usually impresses them, and, I think, makes them a bit more compassionate.
- If you have already picked out your specialty, then consider looking at other clerkships/electives as your first, last, and only chance to … deliver a baby, be inside the abdomen, make sense of a floridly crazy person, etc. Learn as much as you can. At least be open to the idea of trying a new specialty.
- Don’t stress too much. After the first block, you will be fine. If you can, try to review a bit before coming back, but it is not essential. If I had to do the transition over again, I would have read the First Aid Guide to the Clinics and Bates. Alas, I had no time, and was fine without it. You forget a lot during your absence from the clinics, but just remember that your medical student colleagues are also learning everything for the first time. Besides, occasionally medical students (such as yourself) will know more on a particular topic than interns and residents on the team.
- The standardized patient experience sounds like it would have been really useful! MED250 was really useful to remind me of everything I needed to learn/study to be prepared to return to clinics. It might have been useful to have a break of a week or two after MED250 to have time to study to prepare for clinics before actually clinical rotations began for me.
- FYI -- If you aren't really invested in the experience and are leaving early to sneak back to lab each day, people will notice.
2. How did you refresh your history/physical exam skills?
- Reading books
- Most people reread Bates to some degree, if just to look up a specific question. Probably not the best idea to reread the whole thing since it is very dense, but a good starting point.
- “Review the Bates history & physical examination pocketbook. Practice percussing and listening to your own heart for the S2 split and whatnot. Definitely try to do a warm-up, if you can, and practice H&P and presentation skills in real time.”
- Others recommend
- Another option is First Aid for Step 2 CS, which goes through very common & high yield scenarios and has a list of all the questions you want to ask. You will need this book for Step2 and CSI later anyways, so doesn’t hurt to buy early. Plus it is a lot less dense than Bates.
- Practice -- Experiences range from Clinical Connections, MED250, Family Medicine Fridays, Standardized patient refresher, or practicing with a friend.
- Most people do Clinical Connections (and like it!) but it varies a great deal how much actually do depending on the specialty & attending
- Most people liked MED250
- Another option for those who cannot spare two weeks to refresh their skills can do Friday afternoons at Family Medicine.
- Last year students were also offered the option of a new Returning to Clinics Standardized Patients program, but this didn’t exist when we came through.
- Individual suggestions:
- “I looked through my medical school notes and looked at a few sections of Bates. It comes back with practice. The good (but also scary and bad!) thing is that nobody really sees or checks your physical exam skills when you are running around in the wards. So you will make mistakes, but it will be ok, if you just know your limitations and keep practicing.”
- “For H&Ps, a lot of the trick is to get in a good rhythm & order. Try to find a good ordering for the history (CC, HPI, ROS, MED, ALL, PMH, FH, SH, etc) and physical exam (HEENT, neck, heart, lungs, abd, extremities) that works for you and practice a few times and you’ll be fine. “
3. What do you think is essential to go in your white coat?
- Most people use epocrates / micromedex on their smart phone for looking up drugs. There are also small pocket pharmacopia books or online resources like uptodate/lexicomp that you can use. MSG has a list of the most popular medical apps and some are free through the biomed library.
- Most people also have Maxwell’s cards, Pocket Medicine, stethoscope, pens, and mini notepad/index cards.
- Less essential items include: reflex hammer (unless on neuro), mini flashlight (also unless on neuro)
- Some said they did not need anything (“we are still the old-timer generation”) -- “I had no PDA and didn't even buy that little blue medicine back (even for my sub-I) and I did just fine. There are computers everywhere so I don't think this is at all essential. It can occasionally be helpful, but I honestly think it's rare. “
- For surgery, a lot of folks liked carrying Surgical Recall.
4. What do you wish you'd known/remembered prior to returning?
- “The SOM transportation system for HUP, Presby, Pennsy, and the VA, where they will pick up you anywhere between 8th and 48th street and drop you off at your clinical site early in the morning for $2 vouchers. I spent the first 2 weeks with transportation hassles before getting hooked into this system, and recommend it over driving. You can get these vouchers from Suite 100 (Maria Hernandez). Away sites should have ample parking.”
- “That we only need 5 clinical months after core rotations (including sub-I).”
- “I wish I had studied more before I left for the PhD!”
- “More about different drugs, and infectious diseases.”
- “THAT could fill a book. Most of it came back. What i should've worried more about was preparing my presentations. Focus on your presentation skills above all else, that's what you're graded on.”
- “Oh, many many things! Medical knowledge, presentation skills, physical exam skills, procedure skills! But, in retrospect, none of them proved essential to know prior to returning. In fact, residents are still learning that stuff themselves!”
- “I wish I remembered more nephrology and cardiology. When I returned to clinics I knew that the EKG I was looking at was "normal-looking" but had no idea how to count the boxes etc any more, no idea about heart sounds, no idea about cardio meds. The kidneys - sodium, potassium, etc - I had forgotten all of that (and probably will never remember or relearn as much as I want to or should). I'll definitely be calling cardio and nephro consults in the future!”
5. What did you worry about too much?
- “Not knowing enough. Medicine is kinda like riding a bike and you will quickly catch on again.”
- “Remembering the H&P - you do need to brush up, but it comes back to you pretty fast in the clinics.”
- “The hours and the med Sub-I.”
- “Lack of procedure skills. You learn what you need quickly once you do it, and being super at blood draws and IVs is really not as important as I fretted about.”
- “I worried about attendings expecting me to know more that I knew (i.e. not realizing that I had done my last rotation ages ago). In fact, most attendings were super nice and realized that my last rotation was a while back.”
- “How rusty I was going to appear compared to my fellow students who had been in their clinical clerkships for over 6 months already.”
- “Being "behind" as an MD PhD student. I think if you're enthusiastic and clearly trying to learn, it doesn't really matter.”
6. What was the hardest part about returning to the clinics?
- “One of the hardest things for me going back was taking "the game" seriously. The lab was the closest thing I had to a real job with real responsibility, and it is hard going backwards. It has helped me in clinics because I am always seeking out a role, but it can be very frustrating not to find that role as a lowly medical student.”
- “Vaguely remembering things you learned about years before but not being able to recall the terms or speak about them intelligently. That is what being in the clinics is all about! i don't know if there is any remedy for this.”
- “The schedule. I was used to my PhD schedule - although I worked just as hard (if not harder) during my PhD years, my schedule was much more flexible.”
- “Being back on the bottom of the heap and the pony show that is the clinics, particularly after being independent for several years in my lab.”
- “It is a humbling experience to come back to the wards, where you know very little, after having been an expert in your field in your PhD years.”
- “Waking up early”
- “Studying for shelf exams”
- “Being so old and being used to being "in charge" and important. I think the hardest part of being a medical student is feeling so extraneous. It is a very different role. I dealt with this by trying to remind myself that my job was to just to learn.”
7. Did you do a warm-up course? Did it help?
- Family Medicine
- “I did the Family Medicine on Fridays things for a month. It was a nice transition, no stress, and I re-learned a lot of basic stuff that proved to be useful. I highly recommend it.”
- “The family medicine fridays are incredibly helpful - you get a crash refresher course on Peds, Medicine, and Ob/Gyn in a very laid-back setting”
- MED250 – note that the course has been revamped since we came through. But here are some notes on our experiences.
- “Yes – [it helped] immensely”
- “Yes - absolutely a must”
- “Yes, it was helpful to get back into the routine of prerounding, note writing, etc”
- “MED250 was helpful”
- “Med 250. No. Had less than desirable resident though which is big part of it.”
- “No - I didn't have time”
- “It was really helpful to just remind me of the typical schedule and which physical exam maneuvers I had forgotten”
- “I did Med250 and found it very helpful. Like anything else, I think it is very resident dependent, but my resident was great. He made it a laid back experience and just focused on helping us with history and physical exam skills. “
- “It helped a little bit. I would still recommend taking it, as it gives you a chance to review physical exam skills, presentation skills, and a bit of medicine.”
- “Clinical Connections, not the Pennsy one. It helped for confidence and nerves, but questionable for helping with the skills and stuff.”
8. To what degree did you leave the lab after returning to the clinics?
- “I kept my old desk, often go by, and am still working on a paper with my PI. Thus far there has been ample time for this.”
- “Still had papers pending - now, a year later, they are finally getting published. It's doable but I would not recommend it. “
- “100%. I think that was good.”; “Completely”
- “Still trying to get a paper out but haven’t gone back to the bench.”
- “I had my space at the lab for a few months. When I was on campus, I stopped by to see everyone pretty often. I was still finishing up my manuscripts for about 8 months after my official return to the clinics.”
- “Kept doing labwork at least one-two weekends per month”
- “Almost completely during core rotations, but now I'm back since I've returned to electives.”
- “Pretty much didn't do anything in the lab until clerkships were over, but started doing experiments again as I got into electives.”
- “Almost completely (I still coached an undergrad occassionally by email and spent a couple weekends in lab genotyping mice)”
- “I left completely. I'm very happy that I did this because it allowed me to focus entirely on the clinics. I think I did a lot better because of it (in terms of grades) and also had more time to make an informed career choice. “
9. How did you end up choosing a specialty?
- “I did clinical connections a few times, which helped me eliminate some possibilities. I also used AAMC Careers in Medicine you can get a personal code from Helene Weinberg or Barb Wagner. Most importantly, I went with my gut and thought hard about how to integrate my most favorite clinical activities with my favorite aspects of research.”
- “I had heard about RadOnc as a great field for bridging research and medicine with a doable lifestyle. Did a rotation early in January (which is one of the luxuries of being md/phd) and loved it. Had lots of extra time to do some research in the department to get really familiar with it.”
- “Recommendation by my thesis committee advisor to follow an attending in this specialty around for a while during my PhD years. This was part of Clinical Connections and was very helpful for me. “
- “Picked based on the principle that I wanted to use both degrees and figured which specialty would have the best day to day experiences, best research opportunities and most rewarding clinical work.”
- “I liked several specialties, but felt that I derived the most satisfaction from longitudinal care of adult patients. I also thought that internal medicine (and, probably, hematology-oncology) would fit best with my research interests.”
- “Chance. Try and keep an open mind”
- “I decided in the pre-PhD years (based on multiple clinical experiences and lab experiences - it became obvious to me that the specialty was a perfect fit in many ways).”
- “I did rotations in each of the fields I was considering, and after that it was clear.”
- “I did the required clerkship, which I really enjoyed, and then I did an externship to confirm it was the right fit for me.”
- “Clinical Connections to explore possiblities, Attending Grand Rounds of specialty of interest, Finding a mentor in my specialty of interest, Electives"
10. Advice for Timing your return and planning electives / sub-I.
- In the past, many MD/PhDs have returned to clinics in January of the year before they will graduate. However, with the Dean’s letter now pushed up earlier in the year, it is highly recommended that you come back in September – November. This will give you flexibility to take a number of electives (some are hard to get in to), get letters of recommendation, and ace Step 2 with a good amount of time to plan for residency applications and interviews. Since residency interviews are given out on a rolling basis, some going into more competitive specialties have found that a late return to the clinics has put them at somewhat of a disadvantage.
- Helene is very flexible with scheduling and many people come back in the middle of a block. For example, many people do pediatrics early on but push OB/Gyn until after Dean’s letter goes out (unless you are thinking about OB/Gyn as a residency possibility).
- All else being equal, coming back to OB/Gyn, psych, or surgery are great refreshers since they do not require as much knowledge of medicine and give you a relatively long time to study for the shelf.
- A great resource for planning which electives to take and their timing is the Career Night booklet from the year before, which compiles advice from students who have matched in each specialty. It also provides good contacts for where to get specialty-specific advice in case you have questions.
- For those interested in medicine, some students have suggested that taking Step 2 CK before your sub-I is very helpful, since Step2CK tests pretty high yield clinical knowledge.
- Many people end up doing their sub-I in July or August. Which of those months is preferable depends on your situation. In July, you’ve had one fewer elective months, but a more generous time frame for getting letters of recommendation. In August, you’ve had one additional month of elective time, but will feel more pressed in terms of getting a letter of rec. September is generally too late, given that the Dean’s Letter goes out Oct 1.
- Before returning / During Refresher
- First Aid Guide to the Clinics: very useful, starts from scratch
- Bates Physical Exam: review the basics! Also there is a condensed, pocketbook version.
- Symptoms to diagnosis: an evidence-based guide
- First Aid for the USLME Step 2: Clinical Skills -- very high yield chief complaints and good review of questions to ask & physical exam findings to look for
- Step Up Medicine -- comprehensive refresher to medicine
- Lange Case Files Series: active learning for those not used to memorizing off a textbook.
- Core Clerkships -- see recommendations from Guide to Clinics, highlights here:
- Carlos Pestana’s Kaplan review cannot be emphasized enough. It is a very short clinical vignette style that is extremely high yield. There is an audio version floating around that many folks found useful listening to when going to/from clinic.
- Surgical Recall: only good for OR pimping
- USMLE World Question Bank
- Many other recommendations and useful info from Guide to the Clinics, under online resources.
recommended online resources
AAMC Careers in Medicine: (http://www.aamc.org/students/cim/)
Get help with choosing a specialty
Access Medicine: (http://www.accessmedicine.com/home.aspx)
It has numerous texts and most importantly a Lange question bank for USMLE1/2/3 prep. You can pick by clinical subspecialty and the step 2 questions were invaluable prep for the SHELF exams. Plus it's all FREEEEEEE.
Auscultation Assistant: (http://www.med.ucla.edu/wilkes/intro.html)
Review the pathophysiology and sounds of murmurs, rubs, etc
BioMed Library Website: (http://www.library.upenn.edu/biomed/)
Tons of clinical resources!
Guide to the Clinics:(http://www.med.upenn.edu/penn/student/documents/survivalguidetotheclinics.pdf?websec_token=63d96fd4fce11e61defac3f3ed98fc46)The MSG guide to the clinics, with lots of useful info for each clerkship and in general!
Knot-tying and suturing videos: (http://www.bumc.bu.edu/Dept/Content.aspx?DepartmentID=69&PageID=5914)
Be a whiz in the OR!
Well-done medical calculator designed for rapid calculation of common equations used in internal medicine.
Medical Mnemonics: (http://www.medicalmnemonics.com/)
Not used to memorizing? Use a mnemonic!
Microbiology sing-along: (http://www.melissamiddleton.com/microbio/)
Loved the songs in Dr. Helen Davies Microbiology class? Not sure of the words anymore and need a fun way to remember your bugs? Fear not - this website has a compilation of her songs with their intended beats!
Radiology tutorial: (http://www.med-ed.virginia.edu/courses/rad/)
Re-orient yourself to the radiograph!
Practice reading EKGs, ACLS, etc
The gold standard in medical info online