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Returning to Clinics Student-to-Student Guide

The MD/PhD class of 2011 has written this guide to help future students transition back to the clinics after the PhD. Here is what you should know when returning to clinics, how to make the transition as smooth as possible, and how to succeed. Consider this the unofficial supplement to the official advice you should peruse here: 

http://www.med.upenn.edu/mstp/Returningtoclinics.shtml

Disclaimer: Not everyone will agree with every part of this guide and no one strategy works for everyone. We have tried to keep things clear and concise with the highest yield suggestions. Seek additional advice liberally!

DON’T PANIC

Maximize your comfort through preparation, but not to the point of becoming overly anxious or stressed. Remember, everyone coming back is rusty. You will screw up a few H&Ps and a few presentations, just like all of us who came before you. But everything will come back to you with practice and time, and you will grow up to be an outstanding physician-scientist.

Picking the First Clerkship

Keep Maggie in the loop early when planning when and where to come back! Helene is also a friendly resource and full of information. The scheduling process is complicated and tailored to your specific situation. The optimal schedule for any one person depends on several variables, but the collective wisdom is that if your schedule (and the availability) is such that you have a choice, the following are the best choices for coming back.

  • Psychiatry or OB/GYN***, depending on which of those you have not already had. Both are not heavy on basic internal medicine concepts. You will return roughly on par with your classmates who will not have an extensive knowledge base in those areas.
  • The O’s are low stress, pass/fail, and thus a good way to transition into the clinical environment. You can follow this up with psychiatry.
  • As MD/PhD students we do not have to follow the usual sequence of rotations.  Specifically, you may be able to start with electives even before you have completed the clerkships.  For example, if you are considering Pathology, you can easily do a month elective in November or December when there might not be enough time for a full clerkship. 

Try to pick sites that have residents. Our experience is that residents have much more sympathy for medical students, especially new medical students. The residents might be your former classmates, so as long as you were cool with those guys, it can work out really well. Remember to use SUCKRS on the Medical Student Government website to pick the best site and to leave feedback for future students.

***If you are thinking about going into psychiatry or OB/GYN, you do not want to come back on those. In that case, neuro or surgery are not bad choices. Everyone is afraid of the surgery clerkship, but it is actually a great rotation (assuming Dr. Kelz is still the director) even if you have no interest in surgery.

Refresher Course

After your defense, your first priority should be having some way of getting to know how the floors work. You have two options:

  • The Pennsy refresher course provides this experience, and it is very strongly recommended. Two weeks are normal, but in a pinch it can be shortened to one week.
  • Alternatively, you may choose to do Friday clinic at Penn Family Care. It is a very useful refresher for H&Ps and you don’t have to dedicate a full two week block.  Instead you can do it while you are still finishing up in the lab.

Depending your team and resident, they will not push you at all and it is easy to get nothing out of the refresher course. So be proactive and use the information below to ask for things, do things on your own, and integrate as a member of the team.

History and Physical Exam

The first thing is to learn how to be a medical student again. In general your priorities for now should be (in order of priority): prepare good notes and presentations on your patients, prepare topic presentations, and study for shelf. There are a number of resources to help you refresh your memory on how to do the first part, and the bolded resources are the three most essential things.

  • Step 2 CS, as annoying as it is, represents a standard for how to be a senior medical student. The First Aid Step 2 CS book is on reserve at the library, and you can spend an afternoon to a few days reviewing it. It covers the essential components of an H&P, the lingo for notes, and a lot of example scenarios with differentials and plans. This is what you are really expected to know on clerkships!
    • The book “Symptoms to Diagnosis” is a great resource as well. The unique format makes it an easy read and it is very high yield for how to work up patients. First Aid Guide to the Clinics is often mentioned with various degrees of love and hate. There is more emphasis on what to do and how to shine, but this is very team dependent.
  • There are a number of online text resources. My favorite is here:http://blogs.askdoc-usmle.com/preparing-for-the-usmle-step-2-cs-part-i/. They suggest developing a system of mnemonics; for example LIQORAAA PAMHUGSFOSS SODATIME is burned into my brain and this really helps move efficiently through patient encounters. (*** Author note: they removed the SODATIME mnemonic from that website. That one is: Smoking, Occupation, Diet, Alcohol, Travel, Illicit drugs, Marriage/children, Exercise)
  • Go over your physical exam skills, preferably with someone as a practice partner. You can use the full Bates guide to guide you or just the pocket guide depending on how much you remember. There are a series of Bates videos available through the Penn library (search “Bates Videos” and then click in the Multimedia & Video section) and a series of NEJM videos: http://www.nejm.org/multimedia/medical-videos.
  • Along these same lines, if you have time, there are Penn videos that you should consider watching prior to starting the refresher course. These are the Differential Diagnosis lectures (MD 305) and MED200 didactic session on Oral Presentation via Virtual Curriculum (dated 7/12/10 on VC).

Get your system down and practice it in your head or with someone. You will also need to memorize organ-based reviews of systems. If you type “Review of systems” into Google you will find fine templates. Of course be flexible and pay attention to what your team wants.

Practice the full H&P and writing a thorough admission note during the refresher course. Then practice presenting to your residents and attending. The Pennsy admit note template is pretty complete with its checkboxes, so be sure to ask and do all of those things. Try to memorize it so you don’t have to keep looking down.

What things do I need again?

  • Stethoscope, make and model not particularly important
  • Maxwell Quick Medical Reference
  • Reflex Hammer
  • Penlight
  • Pens/notepad
  • Smartphone/PDA equipped with Epocrates, Diagnosaurus, Skyscape, MedCalc
    • This is not entirely necessary. If you do not want an electronic pocket device, consider Tarascon Pocket Pharmacopoeia, Sanford Guide.
  • Rotation specific pocket textbook or study guide. Pocket Medicine for sub-I (maybe refresher course), Surgical Recall for surgery, etc…
  • Short white coat of course. If you lost yours like I did, I bought the “META 30" Men's 6-Pocket Consultation Lab Coat by White Swan”

Daily workflow

For the day-to-day on clerkships, generally do what your interns do. In particular, learn how to use the computer system well to check lab results, check and put in orders, and generate progress notes and patient lists with pre-filled information. Then keep this Pennsy daily workflow in the back of your mind as a guide.


1) Get sign out on your patients.

2) Pre-round on your patients. See them all quickly. Jot down vitals and brief thoughts on each patient as you go from room to room to save time. It is more important to have seen everyone and know what's going on with everyone than to have your notes written unless your team explicitly tells you otherwise.

3) Chart check all your patients for new notes/consultations. Check for new lab results.

4) Write notes and round (the order is team dependent). During rounds take notes on what needs to be done for each patient.

5) Revisit all the charts and labs in the late morning. Then take care of things that need to get taken care of. Get used to calling consultants. It's a bit of a skill that's easy to improve upon and impresses people.

6) Lunch/lecture

7) See all your patients again in the PM. Take care of things that need to get taken care of. Chart/lab check before you leave. If you are done early, ask if there are other tasks like procedures you can do for your team’s patients.

The other very useful resource for getting used to the clinics again is the Medical Student Government website. There you will find a guide to the clinics, patient note templates, and the Penn Med Guide.

How to excel

  • Look enthusiastic even when you aren't, smile a lot, volunteer a lot. Depending on your team, volunteer to give 5-15 minute topic presentations based on your patients’ clinical questions. Aim for one a week or even more, though this is team dependent. Remember that most of your evaluation is based on the social aspects of the rotation--i.e. how much people like you. If you're a natural politician it can be easy to honor everything, but even the all knowing, all doing House MD would probably fail out of medical school.
  • Most students come back off-cycle and so you will be graded against classmates who have been at it for 6-9 months and for whom expectations are higher. It will probably help to mention to your teams (but not dwell on this point) that this is your first clerkship back from the PhD just so they adjust their expectations accordingly. Unfortunately, residency matches for almost all specialties are getting more competitive even for MD-PhDs, so it really helps to do well in 3rd year.
  • Once you are comfortable, try to aim for the next level above you. i.e. Try to pretend to be a sub-I as much as you comfortably can. If you can put in orders for patients, do it. Try to formulate your own plans. Try to take ownership of patients as much as your interns will allow. Get into a good work flow. Take as many patients as you can handle, but aim for four or more. Focus your presentations towards the pertinent.
  • The best way to impress is to know what's going on before your intern. Fill them in. Keep in touch by text message or whatever frequently. Though obviously do not try to outshine your intern--they are in a very insecure position where they are trying to impress the resident/attending as well. Just be on top of everything for your patients and they will notice. Interns love it too when you help lighten their load. As per The House of God: "show me a Best Medical Student who doesn't triple my work and I will kiss their feet." If things run as they should, this load lightening should be repaid to you in teaching time.
  • If you walk out of a room and you really don't know what's going on with a patient, just put the main symptoms into Diagnosaurus. When the attending or resident then asks what you think might be going on, at least you have A LIST to work with. Organize the differential in your mind into some sort of system instead of blurting out random things. That can impress the heck out of them versus you presenting the patient and saying I really don't know what to make of those symptoms. Epocrates is really helpful too. Check on meds for conditions, doses, mechanisms of action, etc…

What to read

If you would like to read textbooks to get up to speed, DO NOT review step 1 material. It is a waste of your time. Do not worry about lack of trivia knowledge. You will get caught up on that nonsense no matter what you do.

  • If anything, start working on shelf exam prep material for your first rotation. For OB/GYN this might be the Blueprints or Case Files book for example, i.e. whatever study guide is in current fashion. Do not read textbooks. They are too low yield and too detailed for now. Uptodate and Emedicine are good for specific questions, but not great as a study resource. For refreshing for general medicine, it might be worth getting Step-Up to Medicine or Case Files. Remember, you want to remember basic concepts in the sense of what to do for specific, common clinical scenarios. This is an “If X than Y” basic flowsheet mentality. It is too much at this point to try to memorize all the percentages and nuances unless you have a patient with a particular condition the resident or attending will pimp you on.
  • Once you get into clerkships, be sure to get the recommended review books for the shelf on that clerkship. There is typically a word of mouth at Penn as to which books to buy, but you can also check Student Doctor Network Clinical Rotations Forum for recommendations. Ignore advice to “read up on your patients” (beyond what is needed for a good presentation/pimping) or to read large textbooks.

Transportation

Remember there is a 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. You can get these vouchers from Suite 100 (Maria Hernandez). Away sites should have ample parking.

Advice on preparing for fourth year

Start getting advising for your specialty of interest early. Hopefully you have been able to participate in clinical connections, but maybe your interests have changed or you have more interests than you were able to find advisors for. Still, even just talking to someone in your specialty of interest for an hour can be very useful. Several students have commented that they did not realize how competitive their specialty of interest would be, and this was a wakeup call to do better in clerkships and/or build in time for step 2 CK before submitting residency applications. Other students have commented that their assigned advisors were not the most helpful, so if you do not click with a mentor, find another one!

All of this guidance may change your timing for the return to clinics, so again we have to emphasize talking to Maggie and your specialty advisors early! Just try not to return to clinics at the absolute last minute. If you can get electives in early this can really help you solidify your residency choice, make contacts in your department of interest, do away rotations, get letters of recommendation, and perform clinical research if applicable to your situation.

Remember that you need letters of recommendation, and this typically means three clinical letters. Start thinking early about which rotations you might get them from. If you work with anyone remotely famous in your career field, even as a 200 student for two weeks, strongly consider asking them for a letter. It usually helps to ask for a letter even if unsure. If you have more letters than necessary, Barb Wagner will pick the best letters for you later.

A list of other recommended resources for the clinics

Continuing in lab after the return to the clinics

Many MD/PhDs will feel that they need to focus completely on the clinics when they return—at least until clerkships are completed and residency applications have been submitted. However, for some, it may be appealing and possible to spend some time in the lab. For some specialties, you may want to focus on performing some last minute clinical research in that specialty for the best residency application. Ask your clinical advisor if this possibility makes the most sense for you. In this section, we will lay out advice for those who want to stay involved with research in their thesis lab during clerkships.

A strong word of caution: DO NOT make promises to your lab-mates or PI. While some students can stay involved in lab, some students find they have to focus entirely on clerkships. This can be for many reasons: need for honors for your specialty, more difficult rotations or sites, or just different requirements for life outside of a medical center. Make your plans very tentative, and make sure everyone understands that you may be too busy to come back to lab for many months after you return to clerkships.

With that disclaimer in mind, for the best chances of being productive, think about some advance planning.

  • The most important thing is to find someone to be your hands while you are away from the bench. The best idea is to start training someone to take over an aspect of your project ideally a year or so before you have to return to clinics. There should be questions remaining pertaining to your thesis when you finish. Choose the most exciting lead and give it away to a new person. They will be overjoyed to have a project that is not a fishing expedition and you should get a guaranteed co-first authorship. While in the clinics it may make sense to take a smaller, simpler project for yourself that is easy to put down and pick up again. Remember, you will really only have time to experiment in the late afternoons and weekends, so do not be too ambitious.
  • If you are God's gift to science you may be able to have your PI to give you a technician for your year away from the lab, but most of us will have to settle for less.
  • Your best bet is an incoming postdoc who has good hands but needs a ready-made project that they can complete reasonably quickly for a solid first publication.

If you spend the better part of the year training someone while you are finishing up your thesis and your assistant is a decent human being working on something related to your projects, they will hopefully reciprocate and help you set up some experiments while you are spending time in the clinics. Concentrate on things that can be done in 1-2 hour chunks of time.

  • Things like cloning or data analysis should be easy to do while still in clinics. Try to make a trade with your new trainee, "if you set up this experiment for me, I will harvest the cells and analyze the data." Of course, they will be expecting a co-first authorship on whatever you end up slapping together.
  • No matter what your plans at the end of your last clinical year, you are going to have to travel the country interviewing for the next step of your career path (residents or post-doc). Time traveling on airplanes and staying in hotels alone can lend very well to writing up remaining data for publication. Also if you stay active in the lab, postdoc and fast-track interviews should be easy.

Effective time management

  • One of the best ways to find time for lab is to schedule all of your rotations at HUP. That way if any free time arises or you are given time to go "read", you can sneak away to lab. When your team calls you back, you can usually meet them anywhere in the hospital in under five minutes. Generally, do not make the mistake of doing everything at Pennsy because it is supposedly easier. You do not get out that much earlier and few will come back to campus after spending a long day at Pennsy.
  • Another trick is to try to make a habit of going to lab every day no matter what, even if only to say “hi” and “bye”. If lab members are going to help you do experiments they are going to want to see your smiling face around at least part of the day. Also going to lab can be a huge time-sink if you do not go very often, as people will want to talk to you about your new life in the clinics and what rotation you are on, etc, etc. Instead, make it a habit of being there most days. People will think it is normal and go back to ignoring you like they did for most of your PhD. Lastly, if you go often you can catch problems before they arise and answer questions along the way. Remember as a recent lab graduate you will be the most knowledgeable one in your particular project and in the issues arising from it. You can help your new trainees stay on track and guarantee collaborative publications will be served up sooner rather than later.
  • One last trick is to remember that clinical rotations often involve a lot of reading. Why not do the reading in the lab?While there studying you can help answer questions for your trainees and take breaks to think about or talk about science. If you are doing lab work you can get reading done during incubation periods.

Although it can be great to hang out in lab when you are supposed to be in clinics, do not push it too far.Some days you will just be too tired or on call or just plain busy to make it to lab. It will not do you any good to fail out of med school and you cannot do anything useful in lab when too tired or rushed.

The most flexible clinical rotations so you can spend time in lab

  • Radiology 300, some lecture time, not much expected of you if you are not going into Radiology.
  • Any clinical pathology rotation, especially molecular diagnostics, except maybe hemepath.
  • Anesthesia 300, generally low hours, not much expected of you, residents are very flexible.
  • The O’s, though they have a reputation for being very easy and even people with no good excuse love to skip out on them, so don’t get in trouble.
  • Medical Oncology, many of the attendings are physician-scientists with limited clinic hours. This way you can work with one or two attendings to learn and be evaluated, yet keep hours limited.
  • Two week rotations are usually graded P/F only. This not only gives you time to check out more subjects, but you do not have to worry about shining and honoring in this case.

And if you have a grant...

The NRSA grant “Cost of Education” (COE) allowance will cover for Step 2 registration fees, textbooks, supplies, and anything else you can successfully argue as being educationally required. Your grants manager will be Ilene Kretchman, so send her any questions or requests.

The End


Good luck!

MD/PhD class of 2011

Guide Contributors: Eric Mellon, Josh Gruber, Martina Lefterova, Kunal Patel, Brett McCray, Alexei Polishchuk, Renuka Nayak, Alejandro Chavez, and the MD/PhD class of 2008 guide with suggestions from Maggie and Skip. (Members of the class of 2012 have also reviewed the guide and endorse the info here).