There is no golden formula for getting great grades in medical College, particularly during the clinical years. Each rotation will have different expectations and responsibilities. These will vary depending on the field, the individual attending physician, and, perhaps most importantly, the residents with whom you work. In general, there are several tenets that will hold true, regardless of the rotation.

Be a Team Player

Actively involve yourself in the tasks that the team must complete. Try to write your notes early in the morning before residents or the attending physician see the patient. Continuously ask yourself about the needs of your patient. For example, if you see your patient in the morning and notice she had a fever overnight, you may want to suggest ordering some labs for her, like a CBC and/or cultures. Document the changes overnight in your progress note and write an order for your labs. Don't hesitate to present your patients during morning rounds and discuss your recommendations. The residents must co-sign all notes and orders, so the worst that could happen is that they cross out your order if they disagree with your management. However, you will have shown initiative and your team will be appreciative of your efforts. It also does not hurt to politely remind residents to co-sign your orders and notes should they overlook to do so, since they are held responsible for doing so at most places. The more aggressive and involved you are with the assessment and management of your patient, the more you will shine and the more you will learn. The worst that can happen is someone will disagree with you.

A good team player also doesn't mind helping out with some of the "busy work" throughout the day. For example, help out by looking up current labs and following up on imaging studies. Your efforts aid in creating good team dynamics (and could mean leaving earlier for the day).

Be Courteous to Everyone

This is a broad category; courtesy should be demonstrated to the house staff, your patients, the residents, clerical staff and nursing staff, as well as to your fellow medical students. Health care requires a team approach. Understand that the nurses, techs and other ancillary staff can be your best friends - helping you find items out on the floor and explaining how things are done. Impoliteness could make for a miserable experience for all involved. Just use your good judgment and you should be fine.

Certainly, courtesy must be shown to all patients. Remember that there is a Code of Professional Conduct for students, house staff and faculty alike. Keep in mind the patient's rights and privacy. For example, avoid interviewing a patient while in the hallway or the bathroom. Respect patient confidentiality by not discussing patients by name in public places. Always try to explain to the patient what you are doing and why, especially with embarrassing procedures such as pelvic or rectal exams. If your patient asks you a question and you don't know the answer, simply tell him or her "I don't know, but I'll find out" and come back later with an answer or with someone who does know. Making up an explanation breaks down your trust with the patient.

There is another unwritten but important rule: wait your turn when giving out answers to questions posed by attendings or chief residents. It does nothing but look bad for you when you choose to cut off your fellow medical student with an answer in an attempt to look good.  

Know Your Patients

Be on top of things. Know the latest lab values and studies and their impact on patient care. Read, read, read. Learn about your patients’ diseases and the treatments for their conditions. It is much easier to retain information when you read and put the knowledge together with a face. It will also be helpful when reviewing for the USMLE Step 2. Track down results from all of your patients for the day; it will save time for the residents and will help you understand indications for certain tests. Try to see as many procedures as possible.  Go with your patients for their bronchoscopies, cardiac catheterizations, lumbar punctures, etc. Take advantage of your time as a student to learn about different procedures.

Ask Questions

You will find that the residents will be more enthusiastic about teaching if you express a genuine interest. Ask relevant questions at appropriate times. Offer to present a topic or research some articles for discussion throughout the clerkship. Choose a subject that would be beneficial to you as well as the other students and residents. Such experiences, you will find, can be the best learning opportunities.

Exhibit Ethical Behavior at All Times, No Matter What

It is important to act professionally at all times. Be honest. You are not expected to know everything, so don't feel the need to act that way. Taking copies of a test or copying questions and answers to share with friends is  cheating and breaks the Jefferson Honor Code.

At the end of each rotation, you will receive a written evaluation of your performance. While knowledge and clinical skill are important factors, integrity and interaction with staff and patients are equally, if not more, important. Each student should strive to show interest and knowledge outwardly without doing it at the expense of his or her colleagues.

The written evaluation is summarized by a grade of Failure, Marginal Pass, Good, Excellent, or High Honors, which appears on your transcript. A separate numerical grade will be listed on your transcript for your national shelf examination score. Currently, every third year rotation except for Family Medicine uses the NBME shelf examination. The raw two-digit score will be curved to reflect the class average. The written comments from your clerkship evaluation are also used in your Dean’s Letter that is sent to residency programs. Also sent to each residency program is a bar graph showing your grade for the clerkship in relation to the grade distribution for the remainder of the class.

Input on the written evaluation will come primarily from the house staff with which you work, including the residents and attendings. Ask for midterm feedback. Every rotation coordinator is instructed to give students midterm feedback but may forget to. Asking for feedback demonstrates initiative and the desire to achieve your best. Ask about areas where you can improve and address them in the second half of your rotation. Pay attention to the comments you receive. Residents tend to be rather insightful and it was not long ago that they were in your shoes. If you are having a difficult time during the rotation, it is much better to bring such concerns to the attention of the course coordinator or course liaison as soon as possible.

The written evaluations are important because the Dean's Office will use these comments in writing the Dean's Letter for residency programs. The Jefferson Dean's Letter is highly regarded because of its honesty in positive and negative comments. Don’t worry - one mediocre evaluation will not significantly impact your letter.

If you feel that you have received an unfair evaluation, you may appeal with the clerkship coordinator, then the departmental chairperson and, finally, the Dean's Office. Appeal can only be made before signing the evaluation. Your grade may be changed if cause can be demonstrated.

The SOAP note will be one of your most important responsibilities as a third or fourth year student. The mnemonic stands for Subjective, Objective, Assessment and Plan.

Daily notes can vary from rotation to rotation, but the general principle is the same: to record the progress of your patient and to give your assessment of the patient’s problems and what the plan is to address each problem. Depending on the clerkship, you may be asked to follow anywhere from two to six patients per day. It is important to be able to budget your time in seeing each patient in the morning and being able to complete an accurate note.

The Subjective aspect of the progress note is a subjective description of the patient's overnight stay (i.e. symptoms not signs). It may be a good idea to include a patient quote, for example, “I feel good this morning but it still hurts when I take a deep breath.” Nursing comments can also be included, especially if the patient is unconscious or cannot communicate. Remember to be as inclusive as possible.

The Objective portion of the note includes the vital signs, physical exam, laboratory results, imaging, and other study results. Tailor the physical exam for each patient and rotation. Always start with the vitals and don't forget the ins and outs for urine, drains, etc. For temperatures, always give the maximum temperature over the past 24 hours (Tmax), as well as the most recent recording (Tcurrent). Note how much of the PRN pain meds are being used, if at all. Some residents will ask you to write the patient’s medication list each day, and others will prefer that you don't bother doing so. However, the most important thing is to know what medications the patient is actually receiving (the patient may refuse some medications), and if there have been any dosage changes. If a patient is diabetic, you should include the accucheck glucose ranges.

The Assessment is essentially a one or two line summary of the patient, incorporating hospital day #, reason for admission, antibiotic day #, post-operative day #, and current medical issues or relevant lab/study results. Although the sample SOAP note lists assessments by organ system separately from the plan below, most students and residents incorporate the assessment and plan into a single organ system based paragraph, described in the next section.

The Plan is the final part of the note and your opportunity to demonstrate your medical knowledge and thought processes. The list can consist of problems (e.g., 1. Renal Failure, 2. Constipation 3. HTN) or Systems (e.g. 1. CV: hypertension. 2. Pulm: no issues 3: Renal: Acute Kidney Injury) depending on the preference of your attending. Recommend labs or treatments. Think of the patient's needs. Some residents or attendings will ask you to write a separate problem list before writing the assessment and plan. In addition to organ system based issues, fluid/electrolytes/nutrition (F/E/N), prophylaxis, and disposition are important and should always be included as the last items on your plan.

Each morning during rounds you will be expected to present patients you have been following.  Try to listen closely to the intern or resident presenting in order to get a feel for pertinent information and points to note.  Here is a sample presentation for a patient with pneumonia:

S: Mr. M is a 54 y/o male with a past medical history of diabetes on Glipizide and a 20 pack-year smoking history, who was admitted yesterday with a fever of 102, shaking chills, shortness of breath, and a cough productive of yellow-green sputum that had been occurring for 3 days. This morning he noted continued cough, again productive but with no hemoptysis. Patient noted pleuritic chest pain that is improving this morning. No dysuria and last bowel movement was 2 days ago.

O: AM temp was 100.2 with a Tmax of 102.6 @ 23:12, blood pressure 128/82 ranging from 115-130 over 72-84, respirations 20, moderately labored and heart rate 98. Pulse ox 98% on 4L nasal cannula and he was 1.7 liters in and 2.2 liters out over 24 hours. Exam was positive for right lower lobe dullness to percussion, increased tactile fremitus on the right, and bronchial breath sounds with fine crackles over the right lung base posteriorly. No wheezing or rubs. Otherwise, the patient was not cyanotic and had a regular rate and rhythm. White count was 23.5 with 90% neutrophils, no bands. At 0500, ABG was 7.46/30/52/84% on room air. House officer was called and patient was placed on 4L oxygen via nasal cannula. Chest x-ray from late last night revealed extensive consolidation of the right lower lobe without pleural effusion; left lung was clear. Sputum revealed numerous gram positive diplococci with polys. Blood cultures pending. Electrolytes and am Accucheck were within normal limits.

A/P: 54 y/o m with DM, significant smoking hx presented yesterday with fever, chill, SOB, and productive cough for 3 days consistent with community acquired pneumonia due to Streptococcus pneumoniae. Today's plan is to continue the ceftriaxone (he is on day one), continue 4L oxygen with pulse ox monitoring and re-examine later on this afternoon.

Some things to always include: patient’s age, pertinent past medical history, hospital day, and reason for admission. Next, give a brief description of the overnight course. For physical exam, begin with vitals and pertinent negatives and positives. Add in labs or studies as you see fit. Conclude with your assessment and plan. Students often find that writing their SOAP notes early helps them organize the morning presentation during rounds because you are essentially giving an abbreviated version of the progress note to the team.

Admitting patients will be one of your daily tasks on almost every service of your third year. The following is an example of admission orders.

Mnemonic: ADV CAAN DIML
Admit to 6 Southwest, Dr. Smith's Service
Diagnosis: S/P TAH/BSO
Vitals: q1h x 2, then q2h x 2, then q4h
Condition: Stable
Allergies: NKDA
Activity: OOB (out of bed) as tolerated
Nursing: Foley to gravity, SCDs (Compression Boots)
Diet: Clear liquids as tolerated
IVF: D5LR @ 120 cc/hr, decrease to 80 cc/hr in am
Meds: Percocet 1-2 tabs po q4-6h prn, Tylenol 325 mg po q6h prn, PCA (patient controlled analgesia.) see attached (usually on a separate sheet in chart), Maalox 30 cc po q6h prn
Labs: CBC in am

General References

• Maxwell Quick Medical Reference - a great quick reference for template notes and exams.
• Epocrates - the most commonly used Palm-based drug reference. There is also an infectious disease program from the same company. Both are FREE, and are wonderful clinical references. This is what most people use their palm pilot for.
• The Sanford Guide to Antimicrobial Therapy - is helpful to carry for everyday anti-microbial look-up.
• Facts and Formulas - a wonderful reference for formulas, graphs and charts.
• Pocket Survival Guide - series is available for surgery, internal medicine, and OB/GYN. It is good for template notes, but also useful for the respective field.
• MDCalc - if there are abnormal labs, make sure you analyze them in your plan. This website is helpful for calculating base deficits, corrected calcium, risk scores, etc.

Pocket Books

Maxwell’s Guide – a terrific pocket book.  The guide contains a lot of great information, including normal lab values, physical exam checklists, mini-mental status exam, post-op note format, and much more.  This is a must to keep in your white coat!

Sanford Guide to Antimicrobial Therapy – updated annually.  Get it, love it.  It not only gives the antibiotic and dosage of first and second choice for commonly encountered clinical conditions but also has a handy list of microbial susceptibilities. Some rotation-specific pocket books are listed in their respective guides.  Some of the better ones are Pocket Medicine for Internal Medicine, Surgical Recall for Surgery, The Red Book for OB/GYN, and The Green Book for Psychiatry.

Text Books

Board and Wards – may be the single best resource for third year.  The book is information-packed and concise.  The section on Internal Medicine is highly recommended.

First Aid for the Wards – Probably too general as a general third year book.  However, there is a book guide in the back (just like First Aid for Step 1) that rates textbooks and pocket books on an A to D scale.

Online Resources

Up-To-Date – the online program-of-choice for Medicine, Pediatrics, and OB/GYN.  UTD is available through JEFFLINE and is the place to go to research cutting edge diagnosis and treatment.  It is frequently updated and contains excellent summaries of the available literature on a myriad of medical conditions.  The website is available at www.utdol.com from campus computers. Be aware that it can only be accessed from computers on campus -- no off-campus access.

Clinical Key – an excellent online resource that includes access to electronic textbooks, evidence-based medicine resources, and patient handouts.

Access Medicine – home of Harrison's Online, Current Medical Diagnosis & Treatment, and many other standard textbooks.

Psychiatry Online – home of the DSM-IV and psychiatry textbooks.

R2 Library – for dozens of books on mixed clinical topics, including drug information, subject reviews, atlases, lab and test interpretation, and good general background.

STAT!Ref – another collection of textbooks on mixed topics. This one includes The 5-Minute Clinical Consult, drug information, a guide to lab and diagnostic tests and a dictionary of medical abbreviations.

Smart Phone Resources

• Medscape
• Epocrates 
• OB Wheel
• Med Calc

Medicine is a very important rotation where you will learn to manage sick patients. Time is spent at an affiliate hospital and at Jefferson. During the course of the rotation, students are exposed to a wide variety of diseases. Most patient encounters deal with cardiac, GI, renal, hematology/oncology, pulmonary, endocrine, infectious disease and rheumatologic disorders.

The time spent at TJUH tends to be the most demanding part of the rotation. Each student is assigned to a specific team made up of an intern, a second or third year resident and one attending supervising the team. Sometimes, you may even have a fourth year sub-intern.

Students are expected to see each of their patients (usually two to four) first thing in the morning before rounds and to write a complete SOAP note. The SOAP note includes a thorough assessment and plan for each of the patient's concerns.  As a third year, it is important to know your patient through and through.  

During rounds with the team, students will present the patients they are following and are often asked questions about their thought process.  Students should carry a list with all of the patients on the service. They should pay attention when “running the list” to tasks for all patients, so that they can help ensure that everything is accomplished at the end of the day. Students can help out with tasks such as calling in consults, following up on labs and imaging, communicating with nursing, social work, and case management, and obtaining records from outpatient offices. Some teams will allow the students to renew any medications on the charts and to write for any new medications or electrolyte replacements needed.  Someone must co-sign all orders and nurses make it a priority to contact them regarding your orders. 

At Jefferson, there are required lectures that cover a variety of general medicine topics (EKGs, physical diagnosis, etc. ). There are also mandatory assignments to complete both individually and as a group. At the affiliates, students tend to have more autonomy, responsibility, and greater attending contact. Students also attend lectures throughout their rotation at the affiliate. Some affiliates offer excellent radiology sessions to the students that go over reading chest x-rays. On the whole, the affiliate experience can be quite gratifying and instructive.

Call

Call is every fourth night at Jefferson and is often every fourth to fifth night at the affiliates. You will be asked to help with admissions and check on patients during the night. Students usually are given one to two admissions while on call. At Jefferson and most of the affiliates, call can involve staying to 9 PM .  You may wear scrubs the day of call.

References

Bold titles are highly recommended.

Text Books

• IM Essentials is both a book and online questions bank that is a concise read before the final examination. This book tests your knowledge of common topics in internal medicine and provides detailed explanations of the answer choices.
• Harrison's Principles of Internal Medicine is the gold standard reference text. Excellent for reading up on specific illnesses with which your patients present. Too long to use as the primary text to prepare for the exam. Available online via Scott LIbrary Web.
• Step Up to Medicine is a good resource for those who like review books similar to First Aid. 
• Current Medical Diagnosis and Treatment (Lange) is a great text that comes out every year in the fall.  Very complete and worthwhile reading during the rotation.  Of particular interest is the “further reading” segment at the end of every section that references up-to-date journal articles and review on the topic.  Available online via Scott Library Web as part of the AccessMedicine service.
• Cecil Essentials of Medicine is an abbreviated version (~900 pages) of the complete Cecil’s.  It is a concise and reasonably complete reference. Some students can read this in twelve weeks if a couple hours are devoted every night.  This is the recommended text for the clerkship.
• Mayo Internal Medicine Board Review is an excellent text that is very complete and to the point. Text is written for residents preparing to take their Internal Medicine boards. At the end of every disorder, there is a summary of the main points you need to know in bullets. There are also board-like questions at the end of each chapter with well-explained answers that follow.
• Rapid Interpretation of EKGs (Dubin) is the most readable EKG text written. Many helpful pointers written throughout the text make it very understandable.
• Blueprints for Internal Medicine and First Aid for Internal Medicine are from the two series that become a staple of most third year's libraries. Step Up To Medicine is another commonly used review text for this rotation.  Far from comprehensive, these books still provide the most common topics with enough information to sound competent on rounds and to perform adequately on the final examination. They are reader friendly, but don't count on preparing any presentations from these sources alone.

Pocket Books

• The Maxwell Guide is the most important pocket guide for all rotations. Get it, love it.
• Pocket Medicine is probably the best pocket book for internal medicine, and is the most popular choice for both medical students and medicine residents. Provides practical information for the floors, with treatment plans and references to the original articles.
• Practical Care of the Medical Patient (Ferri) is another popular pocket reference. Very practical with complete differential diagnosis, commonly used meds, and various pertinent lab tests. Somewhat bulky and heavy.
• The Washington Manual is a great pocket-sized reference. It includes a lot of management-related information as well as pathophysiology. It is one of the larger-sized "pocket" books, and is used far more by medicine residents than by medical students. Probably more detail than is necessary for the IM clerkship.
• Pocket Guide to ECG Diagnosis (Chung) is a handy pocket guide that includes common electrocardiographic abnormalities and common arrhythmias that all medical students and house officers should be familiar with. Excellent quick guide, especially if you are on the cardiac service.
• Pocket Harrison's is a fairly complete handbook that describes most commonly encountered disorders, with some detail of the underlying pathophysiology. Unfortunately, not much is written concerning the management of each disorder. Overall, not a popular book choice.

Online Resources

Up-To-Date is an on-line reference that is continually updated. It contains the most current clinical thinking in an extremely useful format that includes data pooled from the original studies on which the management recommendations are based.  

UWorld is a Qbank that you are familiar with, and it has many Internal Medicine questions.

Applications

Qx Calculate is an excellent FREE app that has many algorithms and calculations from the Well’s Criteria to Pre-Operative Cardiac Assessment that can help you be an all-star during your presentations. Not only say a differential, but say why it would or would not be probable.

MedCalc is another excellent app with algorithms and calculations covering anything from FeNA to hyponatremia.

Epocrates is an excellent resource on medications, interactions, and many other things pharmacy related. 

Final Examination

Internal Medicine uses the NBME shelf examination. The best preparation is going through questions, such as the UWORLD question bank. There are a lot of Internal Medicine questions, so start doing questions early in the block.  Additionally, Step Up To Medicine is helpful if you like having a textbook to read.

Your rotation in general surgery will probably be the most physically demanding rotation during the third year.  The hours are long and the responsibilities are vast, but the OR is a privileged place and being involved in surgical procedures can be an amazing experience.

The surgery rotation includes general surgery and surgical or non-surgical electives. You will receive a grade for each and take the Surgery Shelf Exam at the end of the entire 12 week period.

General Surgery

At Jefferson, the rotation is divided into General Surgery, Transplant, Vascular, Colorectal, Plastics, Breast, Trauma, Cardiac, or Thoracic. At the affiliate sites, the assignment of students to particular services can vary widely. However, the affiliates are usually more flexible if you want to bounce around a few different ORs.  Try to be prepared for cases ahead of time.  If you know that you are scrubbing in on a particular case for the next day, go home and read up on the surgery.

A typical day might extend from 5 a.m. to 7 p.m. and even longer if you're attending rounds later. It is recommended that you get in early enough to write notes on your patients before attending morning conferences. On the first day of the rotation, you will be given some handouts on pre-op and post-op care and on some common procedures. These are very helpful, so read them as soon as possible.

Lectures

Lectures for surgery at Jefferson are held once a week on a morning, sometimes on Saturday mornings, beginning between 6:00 - 8:00 AM.  Attendance is mandatory. Some affiliates have additional lectures for the students rotating there.

Books

• Surgical Recall is a popular pocket book.  It is designed with a question-answer format and presents the most frequently asked 'pimp' questions. Recall is a good resource for reading about cases before you step in the OR.  Highly recommended.
• Dr. Pestana’s Surgery Notes is a brief overview of surgery basics that would be great to read within the first couple days of the rotation, and once again as a short review before the shelf. The trauma section is particularly good in this book.
• NMS Surgery Casebook is the old traditional favorite for the shelf exam. Information is presented in outline format and is excellent, but also includes technical information about procedures that is beyond the scope of the shelf exam and less helpful in the OR than Surgical Recall.
• Surgery: A Case Based Clinical Review is a new book geared specifically for MS3s on rotation and, in the opinion of this author, the superior book hands down. Cases are presented in a logical manner with excellent explanations and a summary page of essential takeaways. Each of the ~60 cases takes 15-30 minutes to read, so it is easy to get through the entire book over the 12 weeks. Each chapter has shelf-style questions and explanations that are almost exactly like the real exam. Highly recommended.
• Access Surgery is an online reference tool through library.jefferson.edu that allows you to look up any topic or procedure and will give you results from all the major textbooks of surgery. Perhaps the best way to prepare for a specific case is to use this tool.
• Essentials of General Surgery (Peter Lawrence) is easy to read with excellent pictures and diagrams but it is long. If you put in a few hours a night reading (between working 15 hour days, eating and sleeping) you’ll be in good shape.
• Cope's Early Diagnosis of the Acute Abdomen is not a book that is necessary to purchase, but it is a great educational book for one of the most ambiguous presentations in surgery.
• The Mont Reid Surgical Handbook is by no means exhaustive, but it is a good supplement for the initial management of common surgical conditions. This is not necessarily the easiest book to carry around throughout the day, but it is fairly good for quick look-up topics.

Exams

There is a clinical OSCE at the end of General Surgery in which students encounter common clinical scenarios and are expected to perform basic procedures, such as suturing, starting an IV, and inserting a Foley catheter. Standardized patients with models are used in most rooms. Students are expected to demonstrate a basic ability to conduct a patient interview and perform common procedures related to surgery. Standardized patients grade students using a predefined checklist.

The written exam is the NBME surgery shelf exam.  This will be taken at the end of the twelve week rotation.  Similar to other shelf exams, the test is 110 questions over 2 hours and 45 minutes.  The focus of the exam is mostly management of surgical patients with a heavy emphasis on trauma and basic medicine.  UWorld is typically the first place to go for practice questions, and if you really need more Pre-Test, Appleton & Lange, Case Files and/or Kaplan QBook are other options of varying quality.

Call

Call is every fourth night and alternates between floor call and emergency admissions (first and second call) at Jefferson.  The affiliates have variable call requirements, but in general it is every fourth to fifth night and involves floor and emergency admissions as well. At the beginning of the rotation, you may have to make up your own call schedule so try to note days you have prior obligations.  Most students learn a lot on call.  Most residents are more inclined to teach while on call, so take advantage of this opportunity.

The Operating Room & Scrubbing

Most third year students are a little nervous about entering the OR for the first time, and you should be since the etiquette, sterile precautions, and almost ritualistic way the OR works makes it a unique environment.  Be constantly aware of yourself and your surroundings because careless mistakes can make you very unpopular very quickly among the OR staff.  You will be instructed on scrubbing procedures early in the rotation. Here’s a brief tutorial:

1) Good etiquette: The first thing you should always do is don a hair cap/net and mask, enter the room, and find the circulating nurse.  Circulating nurses run the room so they really appreciate a conscientious medical student.  Introduce yourself and write your name and year of training (i.e., MS3) on the whiteboard if it’s present in the room. If you are scrubbing in on the case, offer to pull your own gloves and gown. As you become familiar with the process, help out with getting the patient on the table, secured, and ask permission to learn, help out, or perform the Foley catheterization of the patient if applicable.  NOTE: Gloves come in sizes 6.5 to 8.5 typically, and in a variety of materials (watch for latex allergies). Try a few pairs on to find a size that is snug over all fingers so you have tactile sensation, but not too tight that your fingers turn blue. Often you’ll be double-gloving, and many people find it better to have the inner gloves be one-half size up from their outter gloves. For example, if you’re a size 7.5, the inner gloves would be 8.0 and the outters would be 7.5.

2) Scrubbing in: Make sure you have eyewear on before your scrub: glasses, a shielded mask, or the disposable eye shields. Turn on the water with the foot or elbow pedal and break open a pack of scrub soap.  Use the finger nail digger first and then start the scrub.  Use a lot of soap; it’s said that the soap more than the actual scrubbing is what sterilizes your hands.  Start with the fingers and scrub up to your elbow (push the dirt away from the hands) on both sides.  Once you’ve done this for 2-5 minutes with special attention to the hands and between the digits, wash off in the same manner – fingers to elbow.  Note that different hospital ORs use different soaps or waterless rub. Always ask politely if you are faced with unfamiliar materials, and people are usually appreciative that you didn’t contaminate anything. Now that your hands are sterile, walk into the OR back first (be sure not to touch the dirty door with your hands).  Walk over to the scrub nurse.  He or she will hand you a sterile towel (usually green or blue).  Take the towel and dry one hand followed by the other; try to use half of the towel for each hand.  Again, dry off starting with the fingers and moving toward the elbow.  Drop the towel in the laundry bin.  The nurse will unfold a surgical gown for you.  Step into the gown with your hands straight out in front of you. The scrub nurse will then help you glove while the circulating nurse ties up the back of your gown. Once gloved and tied in the back, hand your “dance card” to the scrub nurse, spin counter-clockwise and tie the front of your gown. You are sterile only from just above your nipples to your waist, and only in the front.

It is important to be aware of where your body is at all times with respect to the sterile field. The student's role in the OR is essentially to help out with whatever needs to be done. Usually this means holding retractors so the surgeon can see what needs to be seen. If you are lucky and if you show interest, you may get to close the incision. Many attendings like to ask questions during the procedure, so stay alert. Mentally, review the important structures and vessels in the region so you can shine when asked questions. Although reading about the surgical procedure is a definite plus, most attendings tend to ask you about things that were learned in the first two years (e.g., anatomy and physiology).

SOAP Notes

Surgical progress notes tend to be shorter than notes on other rotations:

POD# (post-op day number)
S: No c/o, +flatus, fever/chills?
O: Vitals: T, Tmax, BP, HR, RR, Pulse ox, I/O's, drain outputs, etc.
     CV: RRR, no m/g/r
     PULM: CTA BL, no w/c/r
     AB: +BS, soft, NT/ND, +/- guarding, +/- rebound
     INCISION: c/d/i (clean/dry/intact)
A/P: POD # s/p (status post) lap chole (laparoscopic cholecystectomy)
Will advance diet to house as tolerated
CBC in a.m.
IS q1h wa (incentive spirometry every hour while awake)
D/C (discontinue) Foley in a.m.
Operative note:
Pre-Op DX: Cholecystitis
Post-Op DX: Same, common bile duct stricture
Procedure: Lap chole, intraop cholangiogram
Surgeon: Dr. Gross
Assistant: Resident, MSIII
Anesthesia: GET (general endotracheal)
Specimen: Gallbladder, bile duct stone
Drains: Foley to gravity, NGT
Fluids: 1500 cc crystalloid, 500 cc Hespan
EBL (estimated blood loss): 300 cc
Complications: None
Findings: Enlarged gallbladder with stones, common bile duct stricture
Disposition: Patient tolerated the procedure well. Patient stable, extubated and sent to PACU.

Surgical Subspecialties

Anesthesiology

Anesthesiology is pharmacology and physiology in action. There is not much patient care during this rotation, but you will get to practice IV/A-line placement and intubation. You are given freedom to see, do and attend as much or as little as you want. There is plenty of downtime during this rotation. Students typically arrive around 7 a.m. and stay as long as their residents request.

Grade based on:

1. Thee evaluations distributed to people with whom you have spent significant time (50%)
2. Final exam (50%)
   
3. Prepare a presentation for an Honors grade

The exam is approximately 50 questions. Most questions are based on the handout they give you at the beginning of the course.

Required text: None. The department provides a syllabus that some students find helpful. The lecture on the first day is also very useful for exam purposes. The exam is difficult, but with the aid of the syllabus and the first lecture, you should not have a problem. 

Ophthalmology

Ophthalmology is a chance to get exposed to life at Wills Eye Hospital, one of the country's best eye hospitals. A typical day runs from 8 a.m. to 5 p.m. There are lectures every morning for students given by a resident from 8 to 9am. You are assigned to a different clinic or private doctor's office each half-day; some are required (see below). Students get to learn how to use the direct ophthalmoscope, indirect ophthalmoscope, slit-lamp, and refraction techniques. Three nights of call are required in the ER from 5-9 p.m. during the rotation. Students are usually sent home earlier than 9 p.m. unless they express an interest in ophthalmology.

Grade based on:

1. Fundus drawing on 1st day
2. Attendance at CPEC*, ER, private doctor's offices, lectures, chiefs' rounds (required)
   * Wills hires an attending to teach you during CPEC (Cataract & Primary Eye Care service)
3. Take-home exam

The exam is quite difficult, necessitating the use of outside ophthalmology textbooks (one is available on MDConsult), the Internet, and morning lectures. The exam is given to you on the first day of the rotation so you have 3 weeks to complete the exam. The questions vary from block to block but each exam is 15 questions long. Answers are short answer/essay limited to <250 words per response.

Required Text: Basic Ophthalmology (Bradford 1999) will be supplied by the rotation for free. Morning lectures are based from this textbook. A Near Vision card will also be provided to you.

Orthopedics

This rotation is designed to give you a taste of different areas of orthopaedics. As students, you spend significant time in the OR where you will be asked to retract, especially on joint cases. Occasionally you will also get to suture, hammer, and, possibly use the saw. Students also spend time in the outpatient offices of different attending physicians and attend radiology rounds and morning report (site dependent). Topics highlighted on this rotation include: indications for surgery, anatomy, post-operative care, surgical technique, and common orthopaedic injuries. Those interested in orthopaedics as a career need not be concerned if they do not get Jefferson as their site. This course is only an introduction and most of the affiliate sites have Jefferson orthopaedic residents and Jefferson affiliated attendings, who are great teachers.

Grade based on:

Grades are largely based on resident feedback. To qualify for high honors, in addition to receiving honors on resident feedback, the student must show interest and involvement in orthopaedics by achieving one of the following:

1. Take 4 evening calls over the course of the three week rotation.
2. Topic presentation, if applicable for your service/attending/resident.

Required text: There is no required text for this rotation, but OrthoBullets is a fantastic online reference for nearly everything and they have an app with a great interface.  Orthopaedic Secrets is an excellent “Q&A” format book for medical students covering nearly every topic and written by one of the Jefferson faculty.  Other resources include Physical Exam for the Spine and Extremities by Hoppenfeld, and Musculoskeletal Medicine by Bernstein. Hoppenfeld’s Surgical Approaches in Orthopaedics is used by nearly every resident and is a great way to review the anatomy you’ll see in each procedure. It’s very expensive, but available for free online through library.jefferson.edu. Know your anatomy! Netter's Concise Orthopaedic Anatomy is a great reference text and can fit in your white coat.

Otolaryngology

This rotation gets your feet wet in the world of ENT. If you are interested in pediatrics, this is the only IDEPT 410 rotation offered at duPont. Students often go on morning rounds starting at 6:45 a.m. with the residents and then spend the majority of their time in the OR from 7:30 a.m. on. 

Grade based on:

1. Clinical evaluations.
2. Attendance at office hours one time during rotation.
3. An optional 10-20 minute presentation may get you honors depending on the site.
4. No Exam

Required text: Primary Care Otolaryngology is given to the students for free. With no exam, this book is a good keepsake for the future and has some helpful pictures and techniques. A packet of articles is also given at some sites, which the students are free to keep.

Urology

This rotation allows the student to learn about the field of urology and spend a lot of time in the OR. Students typically arrive around 7:30 a.m. for OR cases and are done by 5 p.m. at the latest, often much earlier. There is also an opportunity to attend office hours.

Grade based on:

1. Required presentation at the end of the rotation given to Jefferson residents and attendings.
2. Clinical evaluations.
3. No exam

Required text:  The Urology department may have textbooks to loan to students during the rotation.  This is not required but may help prepare for the presentation and OR time.

Neurosurgery

This rotation allows students to learn about the fields of neurosurgery and interventional neuroradiology.  Students typically arrive around 6 a.m. for morning rounds and then scrub in on OR cases for the remainder of the day.  The surgical procedures are often longer than those encountered during a general surgery rotation, but the cases are often spectacular.

Grade based on:

1. Daily attendance at morning rounds and in the OR.
2. A 10-15 minute optional presentation to residents and attendings may earn you a grade of honors.
3. No exam

Required text: Greenberg’s Handbook of Neurosurgery is loaned to students during the three-week rotation for use as a reference text.

This rotation involves Gynecologic Surgery, Obstetrics, and Outpatient Gynecology. Depending on the location of your rotation, you may have the opportunity to participate in Maternal Fetal Medicine, Urogynecology, Reproductive Endocrinology and Infertility, and Gynecological Oncology. At the beginning of the rotation, you will receive a patient teaching session on the gynecological exam. During the patient teaching session, you are taught the proper techniques and communication and counseling skills. Communicating with your patient is as important as doing the actual exam.  

Call

Most sites ask for a week of night float on labor and delivery in place of call. Take advantage of the constant activity and hands-on opportunities.

The OB/GYN Department provides a packet with examples of admission notes, delivery notes, pre- and post-op notes, and progress notes, as well as general procedures and concepts of ob/gyn.

Resources – texts in bold are highly recommended

• uWISE is a set of quizzes on the APGO website. The questions have detailed explanations covering major topics in ob/gyn.
  
• UWorld has a thorough ob/gyn section. The questions cover the majority of the topics on the NBME.
  
• Obstetrics, Gynecology & Infertility (Gordon) (the little red book) is probably the best pocket book for the rotation, addressing immediate patient care.
• Essentials of Obstetrics and Gynecology (Hacker & Moore) is the recommended text for this rotation. It is well written and covers all of the essential topics.
• Obstetrics and Gynecology (Beckman) is slowly gaining popularity among students.  There are 40-100 questions at the end of every chapter that are an excellent review for what should have been gained from the text.
  
• Bedsider.org is a user-friendly website where patients can explore and compare contraceptive methods.
  
• www.reproductiveaccess.org has great handouts for patients on contraception, miscarriage, and abortion.

Apps

• Preg wheel is an app that calculates gestational age using estimated due date or last menstrual periodNotes.
• PocketRx is an app with drug information, interactions, dosages, precautions, and side effects. Useful when considering contraceptive options. 
• LactMed is a NIH database of drugs and dietary supplements that may affect breastfeeding. It includes adverse effects in nursing infant and alternatives to those drugs.
• CDC Contraception provides information about selecting appropriate contraception for patients with medical comorbidities.

Notes

Most OB/GYN patients stay 2 days after a vaginal delivery and 3 to 4 days after Cesarean section. Notes tend to be very brief and to-the-point. You will ask about signs of preeclampsia (SOB, CP, epigastric/RUQ pain, HA, vision changes), whether they are voiding and stooling, ambulation, post-partum contraception, and breast vs. bottle feeding. In your physical exam, you will check the height of the uterine fundus, check the pad if concerned about bleeding, and the incision if the patient had a C-section. Operative notes for a TAH/BSO or C-Section are the same as the surgery op note.

0600 MSIII OB/GYN Progress Note
S: Mrs./Ms. _____ is a __ y/o G_now P_ who delivered by ___ at __ weeks on (date) now PPD/POD #. Prenatal course complicated by ____. This morning complains of _____. Tolerating _____ diet, +/- nausea/vomiting, +/- flatus/BM.+/- vaginal bleeding. Pain control (excellent/fair). Voiding/Foley. Ambulating? Infant status: breast/bottle feeding, in the well-baby nursery/NICU. O: Vitals (T/Tmax) BP/RR/HR, Ins/Outs (Mg and C-Section patients). If foley in place calculate UOP since OR.
GEN:
CV:
PULM:
ABD: Fundal height (usually measured by "U" meaning from umbilicus; e.g. U+5), consistency (firm/soft) and tenderness, incision comments (c/d/i)
GU: Lochia
EXT: calf TTP, edema, SCDs in place, reflexes (especially Mg patients)
MEDS:
LABS: (mainly HCT, also Mg level, sometimes electrolytes)
A/P: __ y/o G_ now P_, Postpartum day __. s/p (type of delivery. Issues/complications? Recovering well?
Plan is just like the surgery note, but make sure to include contraceptive plans as well.
Neuro: excellent/fair pain control on _____(medications, note if IV or PO)
CV: stable
Pulm: stable
GI: tolerating ____diet.
GU: adequate UOP, voiding spontaneously (or T/C removing foley and trial of void if appropriate)
Heme/ID: afebrile, f/u on AM CBC, on iron (if anemic)
OB/GYN: routing PP care in 4-6 weeks.  Contraceptive plan.
PPx: SCDs, encourage IS, OOBDon’t worry if the sample note looks like gibberish right now – you will get the hang of things quickly once the rotation starts!  The attending will go over a sample note on the first day of the rotation that will help things become a little more clear.

Exams

This rotation uses the NBME shelf examination.  A combination of uWISE, UWorld questions, and any of the texts recommended above will prepare you well.

Additionally, a clinical OSCE exam is given at the end of the clerkship that emphasizes basic physical exam techniques and procedures in OB/GYN.

Abbreviations

You may want to print out the following segment of this guide and carry it around with you on your OB/GYN rotation.

Psychiatry treats patients with disorders of cognition, mentation, and mood.  The psychiatry department hands out a great outline of the expectations for students on the first day of the rotation.  As with all rotations, it is a good idea to ask your residents and attendings at the beginning of the rotation about their expectations for the course.  All students are encouraged to ask for mid-term feedback and follow through on any suggestions.

The psychiatry clerkship is one rotation that must be completed in Philadelphia, either at Jefferson, Belmont, or Einstein.

The Jefferson rotation has the following options:

• Consult & Liaison – Medical inpatients requiring psychiatric consults.
  
• 14 Thompson – Locked inpatient psychiatric ward.
• Geriatric psychiatry – Elderly inpatient service.
• Outpatient, Drug & Alcohol – A mixture of outpatient counseling through rehab as well as general outpatient observation.

To do well on the rotation, spend as much time as possible with your patients and read about their conditions in your off time.  Psychiatry as a field has been revolutionized by pharmacology.  A review of psychopharmacology will pay off during the clerkship.  There is an opportunity at all sites to spend a day at Mental Health Court.  This day is highly recommended; students have an opportunity to see how patients are involuntarily committed and retained.

Textbooks – bolded books are recommended

• Psychiatry for Medical Students (Waldinger) may be the best written textbook for any clerkship.  It is a good read and very interesting.  One caveat is the 3rd edition is a bit out of date and a newer pharmacology resource is recommended (i.e. the book states tricyclics are still the first-line therapy for depression).
• DSM-V – The resource for diagnostic psychiatry is available in a number of pocket, textbook, and online versions (STAT!Ref).  Most students like to carry around a pocket version or some equivalent (the little green book is highly recommended).
• Blueprints or First Aid in Psychiatry – As always the Blueprints and First Aid series comes through with concise, yet perhaps superficial, review books.
• Human Behavior: An Introduction to Medical Students (Stoudemire) is not as easy to read as Waldinger, but it is also recommended by the department.
• Psychiatry/Behavioral Science (Board Review Series) is an excellent review book. Easy reading.
• Review of General Psychiatry (Goldman/Lange) is well-organized and concise, with good illustrative cases.
• Psychiatry (Hahn) is a great pocket-sized book for quick and easy reference. By no means is it comprehensive, bit it does list general information in outline format.

Lectures

The department holds a weekly half-day of lectures. Keep in mind that the department now uses the NBME shelf examination so be sure to review from a standard book.

Call

At Jefferson, you are required to take two or more nights of ER call depending on the number of students. Call is a great opportunity to work up a patient and provide diagnoses on your own.  The residents you work with evaluate your performance for each call night and this grade factors into your final grade for the rotation. For Jefferson, no matter which service you work with during the day, you will take call with the team from 14 Thompson. Affiliates vary with respect to required call nights.

Evaluating Patients

In psychiatry, the Mental Status Examination (not to be confused with Folstein’s Mini Mental Status Exam) replaces the physical examination.  On an inpatient service you may be asked to perform a more comprehensive physical examination but your focus should be on the Mental Status Exam.  There are great introductory lectures at the beginning of the clerkship.  Another unique aspect of psychiatry is the five axis assessment (see example below).  It is also a good idea to look at a few sample psychiatric H&Ps at the start of your rotation to get an idea of what is important.

Follow the example assessment and evaluation below:

Psychiatric History

Identifying information - age, sex, marital status, race
Chief complaint - reason for consultation, a direct quote from the patient
HPI (History of Present Illness) - current symptoms, previous psychiatric symptoms and treatments, reason presenting now, mnemonics to use: SIGECAPS (depression), DIGFAST (bipolar mania), CAGE (addiction)
Past Psych. History - previous and current psychiatric diagnoses, history of treatments (include both outpatient and inpatient), psychiatric medications, history of attempted suicides and potential lethality
Past Medical History - current and/or previous medical problems with treatments
Family History - relatives with history of psychiatric disorders, suicide or attempts, alcohol or substance abuse
Social History - source of income, level of education, relationship history, support network, individuals living with patient, current alcohol or drug use, occupational history
Developmental History - family structure since childhood, relationships with parents, peers and siblings, developmental milestones, College performance

Mental Status Exam

General Appearance and Behavior - grooming, level of hygiene, clothing characteristics, unusual movements, attitude, interactions with the interviewer, psychomotor activity (agitation or retardation), degree of eye contact
Affect - external range of expression (described in terms of quality, range and appropriateness). Types could include flat, blunted, labile, and wide range
Mood - internal emotional tone of the patient (dysphoric, euphoric, angry, anxious)

Thought Process - may include any of the descriptions below.

Use of Language - quality and quantity of speech. Note tone and fluency here
Common Thought Disorders:
Pressured Speech - rapid speech, especially with manic disorders
Poverty of Speech - minimal responses
Blocking - sudden cessation of speech
Flight of Ideas - accelerated thoughts that jump from idea to idea
Loosening of Associations - illogical shifting between unrelated topics
Tangentiality - thought which wanders from the original point and does not return
Circumstantiality - unnecessary digression which gets to the point eventually
Echolalia  - echoing of words and phrases
Neologisms - invention of new words by the patient
Clanging - speech based on sound, such as rhyming and punning, rather than logical connections
Perseveration - repetition of phrases or words in the flow of speech
Ideas of Reference - interpreting unrelated events as having direct reference to the patient

Thought Content – may include any of the descriptions below.

Hallucination - false sensory perceptions (auditory, visual, tactile, gustatory, olfactory)
Delusions - fixed, false beliefs firmly held despite contradictory evidence
Persecutory - others are trying to cause harm or spy with intent to cause harm
Erotomanic - false belief that a person of higher status is in love with the patient
Grandiose - false belief of inflated sense of self-worth
Somatic - false belief of having a physical defect
Illusions - misinterpretations of reality
Derealization - feelings of unreality involving the outer environment
Depersonalization - feelings of unreality (being outside of your own body)
Suicidal and Homicidal Ideation - desire to harm self or others

Cognitive Evaluation

Level of Consciousness
Orientation - person, place and date
Attention and Concentration - repeat 5 digits backwards or spell "world" backwards
Short-term Memory - recall 3 objects after 5 minutes
Fund of Knowledge - name 5 presidents or historical date
Calculations - subtract serial 7s, math problems (simple)
Abstraction - proverb interpretation
Insight - ability of patient to display an understanding of his current problem
Judgment - ability to make realistic decisions about everyday activities

Physical Exam

Lab Evaluation of Psychiatric Patient - can include any of the following: Chem-7, CBC, TFTs, RPR (VDRL), Vitamin B12, Folate, UA, BAL, urine toxicology, medication levels, HIV

DSM IV Multiaxial Assessment

Axis I: Clinical Psychiatric Disorders
Axis II: Personality Disorders
Axis III: Medical Conditions
Axis IV: Psychosocial Problems
Axis V: Global Assessment of Function

Plan of Treatment

Notes

Progress notes in psychiatry differ depending on the service. Use your resident's notes as a guide and be sure to include a good assessment and plan formulation. Psychiatry stresses discharge planning (i.e., what needs to be done to discharge the patient, as well as subsequent follow-up from a bio-psycho-social standpoint). 

Evaluation

The actual final clinical grade at Jefferson is based on clinical evaluations, call nights, and a final case report. The psychiatric case report (final H & P) is typically due the fifth week of the rotation.  Try to select a patient you would like to write up early on. The nature of the report depends on the service you are on. Since it will be an attending on your service that evaluates the report, it is best to talk to him or her to know exactly what is being graded in the report.

Exam

Psychiatry uses the NBME shelf examination.  A question book such as Pre-Test or Appleton & Lange is recommended or completing the UWorld Psychiatry block of questions. Many students comment that the test has a lot of “medicine” after taking the exam so it may be worthwhile to review some internal medicine.

Pediatrics is the study of young people.  Among other things, you will learn about care and nutrition of newborn infants, developmental milestones, immunization schedules, well-child care, and disease states in children.  It is important to learn what is normal and abnormal in child development and health. Some say there are two patients in the room during a pediatric encounter – the child and the parent. Parents will often be anxious when their child is sick. Reassurance is a big part of the job. During your pediatrics rotation, you may rotate through the inpatient ward, the newborn nursery/NICU, outpatient offices, and/or the emergency department.

Textbooks – bold texts are recommended

• The department recommends Nelson Essentials of Pediatrics and Oski's Essential Pediatrics. These are good reference books to read up on suggested topics, but may be difficult to read cover-to-cover in six weeks. In addition, the 5 Minute Pediatric Consult (written by Jefferson’s own Dr. Chung) is a great resource to come up with a differential diagnosis.
• Rudolph's Fundamentals of Pediatrics is a great reference for the course and modules.  Don’t expect to read it cover to cover but it is a good companion book.
• Blueprints in Pediatrics is a great book to use for both the rotation and for studying for Step 2 of the boards. Blueprints highlights the important aspects of pediatric conditions, but you may need to go to a textbook for more details and pictures.
• PreTest Pediatrics is a great resource of questions that will prepare you well for the shelf exam.
• BRS Pediatrics, while a bit outdated, still provides a great outline based resource covering nearly all aspects of pediatrics on the Shelf Exam. This resource remains one of the most recommended resources.

Evaluation

Modules: The modules consist of a packet of patient scenarios that you will review with attendings during the clerkship. These can be time-consuming, but they address a vast amount of relevant pediatric information.

Written Exam: The written exam is a standard multiple-choice NBME shelf examination. A suggested topics list should be available for some guidance of what to study. As mentioned above, the modules should be helpful in studying for the exam.

Observed Patient Encounters: As part of the rotation you must have four observed patient encounters (two outpatient, one inpatient, and one newborn nursery) with a feedback form completed by either a resident or attending.

Videotaped H & P: You are required to have one patient encounter videotaped to review with an attending. This encounter is purely for your education. You are not graded on the encounter itself, but you are required to review and receive feedback from an attending.

Formal H & P Write-Up: As is the case in many rotations, you must complete a formal case write-up of either an inpatient or outpatient encounter, depending on rotation site. You will be provided with the grading rubric as well as example write-ups to ensure you complete the write-up appropriately.

Notes

Notes are written in the standard SOAP format with a few modifications (refer to Internal Medicine for proper SOAP note format). Always ask early how the resident/attendings like the notes to be written and then present your notes on rounds exactly as written. When a child's parent is not available when you are pre-rounding, it is especially helpful to ask the nurses how the patient did overnight and read the nursing notes. Daily weights should be recorded since medications are mostly weight-based. Plotting a child's measurements on a growth chart may be important. For fluid intake, "ins" are written as both total and in "cc/kg/day" values. For "outs", both total and "cc/kg/hour" values are calculated. Also, be aware that there are different normal values for vital signs such as respiratory rates, heart rates, and blood pressure depending on the age of the child.

One of the best ways to excel in any rotation is to be well versed in the pathophysiology, diagnosis, and treatment of commonly encountered conditions. UpToDate is an excellent encyclopedia type resource that can be accessed through Jefferson to review your patient’s ailments and expand your knowledge of relevant subjects. One of the best parts of this resource are the diagnostic and treatment algorithms that help determine the “next best step.”

Pediatrics in Review: This publication by the AAP provides great reviews of pathophysiology, diagnosis, treatment, and standards of care for common and uncommon pediatric conditions. All full texts can be accessed through Jefferson’s library and through the link above. Reviewing articles regularly will help you shine on the rotation as well as prep for the Shelf Exam.

The best way to study for the exam is to work on practice questions. The most consistently recommended resources are the USMLE World Pediatrics section as well as PreTest Pediatrics. The key to using these resources correctly is to study the explanations and not just understanding why an answer is correct but why the others are incorrect.

Additionally, the Emma Holliday review of Pediatrics is a great resource to review close to exam time.

Call

The call schedule varies depending on where you are rotating but required call is rare during your pediatrics rotation.

Family medicine is one of the few outpatient experiences you will have during medical school. On this rotation, you will manage many of the common outpatient health concerns, as well as learn health maintenance and preventative medicine. Different supplemental reading materials are provided at different locations. It may be worthwhile to share with friends who are doing rotations elsewhere.

Family medicine truly puts your ability to apply the biopsychosocial model to the test. The rotation is a good opportunity to hone your physical exam skills. Remember that you are one of the patient's primary sources of care. Therefore you need to address all of their medical problems. A detailed history and careful physical exam is as important as the lab tests you will order in establishing the correct diagnosis. Your progress notes should be concise and focused in SOAP note format.

Visits are of three kinds: acute sick visit, management of a chronic illness, or health maintenance.  For a sick visit, restrict your history and exam to the immediate problem. The assessment and plan should include a differential diagnosis with support from history and physical exam.

Management of chronic illness visits may include blood pressure checks for hypertensive patients, check-ups for patients with diabetes, etc. This type of visit requires a physical exam targeting all of the end organs that can be damaged in these diseases. Some find it easiest to approach the assessment and plan by organ system.

Health maintenance issues should be listed in every assessment and plan, even if they are not addressed at that visit. A health maintenance visit usually includes performing a complete physical exam and addressing important preventative issues for the individual's age. Screening tests should be stressed, including colonoscopy beginning at age 50 and annual mammography for women over 40.

Family physicians address a number of psychiatric problems. The time spent with the patient should be considered a "psychosocial" exam. You will glean essential information about the patient during this time by observing their affect, their interaction with you, and any stressors in their lives. You may hear the most telling comments as your hand touches the doorknob to leave the room. It is worthwhile to take the time to discuss issues of concern with your patients. These understated concerns may be the true reason they are seeking medical help.

Online Journals and Texts

• American Family Physician is an online journal with excellent review articles on many subjects relevant for medical students. It is also available via the JEFFLINE E-Journals page.
• Hospital Practice is another excellent online journal, much in the same vein.
• Shots & Immunizations by the Society of Teachers of Family Physicians (appstore) is helpful for remembering vaccine schedules for both children and adults.
• ASCVD risk calculator (app store) is useful for calculating cardiovascular risk scores.
• AHRQ ePSS is an excellent app that streamlines the USPSTF screening guidelines, all you have to do is enter your patient’s demographic information and it will tell you what screenings they need.

Text Books

• Essentials of Family Medicine (Sloane) is the recommended text. The text is very useful for exam preparation, but is too dense to expect to read the whole text during the 6-week rotation.
• Blueprints in Family Medicine is probably the most popular text for third year students.  Definitely readable in the six weeks.
• Your Pediatric and Internal Medicine texts may be useful for this rotation.

Exam

The national shelf exam for this block is similar to other shelf exams. There are 100 questions administered on a computer. Preparing with questions from the AAFP online database can be very helpful.

This course offers an OSCE at the end of the course. Cases are geared towards counseling and communicating with patients with emphasis on the bio-psycho-social model.

Call

Expectations can vary depending on location. Some Saturday or evening call is expected.

Sites Offered

Before ranking your site locations, think about whether you would prefer a rural, suburban/small town, or urban family medicine experience. They all offer great teaching and different perspectives on medicine. This may be your only opportunity to practice medicine like Norman Rockwell would have painted!

Course Description

This course will provide students the opportunity to care for a broad spectrum of patients with musculoskeletal problems in the outpatient setting. Each student will work with the same provider on each day of the week for four weeks, to allow for continuity with faculty, increased responsibility and skill building. Students will refine and enhance their skills in musculoskeletal medicine from four different perspectives: the orthopedic surgeon, physiatrist, podiatrist, and sports medicine specialists.

Two 4-week sub-internships (Sub-Is) are required in the fourth year:

• The Inpatient Sub-I can be taken in Internal Medicine, Surgery, Pediatrics, or Family Medicine*.
• The Outpatient Sub-I can be taken in Internal Medicine, Family Medicine, OB/GYN, Psychiatry (2 types), or Pediatrics.

Sub-Is give you the chance to act as the doctor. You are given the responsibilities of an intern, but have fewer patients to follow. You will learn a great deal during these rotations and you will certainly gain a great deal of confidence.

Many students use the Inpatient Sub-I as an opportunity to shine, and by doing so, hope to receive a letter of recommendation. For this reason, many students try to schedule the rotation early in the fourth year.

At the same time, some students enjoy a Sub-I at the end of the fourth year to help with transition into residency.

Most residency programs require three (or four) letters of recommendation on your behalf. You are allowed to submit up to four evaluations for each program. The general rule of thumb is to get a letter if you did well in a rotation and established a good relationship with an attending. Resident or Fellow letters, even from a chief resident are generally not acceptable. Some programs require at least one, if not two letters from an attending in the field you wish to enter – check with your specialty advisor or the Dean’s Office. Some tips for getting letters:

1. If an attending offers to write you a letter – say, “Yes, please!” You do not have to use every letter you get. In fact, you can pick and choose which letters to send to each residency program you apply. This means you can get ten letters and pick any four or the same four for each program to which you apply.
2. It is good to have at least several uploaded when you submit on September 15. Generally, all Letters of Recommendation should be uploaded by October 1.
3. Letters from third year are good to have, but not a prerequisite. The more letters you get third year, the more relaxed the beginning of fourth year will be. Instruct the letter write to hold onto their letter until ERAS is open, and then you can send them the PDF Letter of Recommendation request.  If you can't get a letter third year, don't panic. You have plenty of time in the beginning of fourth year. Also, attendings expect you to ask for letters on your fourth year rotations.
4. Try to ask for a letter at the end of a rotation or as soon as you get a grade back if you are unsure how your final evaluation will turn out. The fresher you are in the mind of the attending writing your letter, the better the letter will be.
5. Give your letter writer a copy of your CV,  Personal Statement,  and Letter Request Form. Waive your right to view the letter. It’s just one of those things.
6. Medicine electives tend to be better opportunities to get letters than Sub-Is for those going into Internal Medicine. For surgery, however, Sub-Is might be a better opportunity to meet an attending and shine. Ask students in the years ahead of you who are appropriate attendings to meet for the field you wish to enter.
7. Don't worry if your letter is from a younger attending as opposed to the chairman of the department. If the younger attending knows you better, it will be a better letter. However, if the chairman knows you, it never hurts to ask.
8. If you are going into internal medicine (or for some preliminary programs), you will need a "chairman's letter" that is an summary of all of the IM evaluations you have received. This counts as one of your three letters for some programs and everyone gets one.
9. Letters from researchers can also be good letters if a researcher MD knows you well; however, they probably will not be able to comment on your clinical skills ability. You can offer to go to office hours with them one day so they can get a sense of your clinical prowess, or do a clinical elective with them. If this is not feasible, a research letter is still okay but balance it out with three clinical letters.

There is much anxiety around 4th year and scheduling 4th year because you are worried about letters of recommendation, away rotations, ERAS, interview season, and maybe even deciding between two or more specialties! Don't worry - you're not alone. We have all been there, it will work out! This guide is meant to hopefully answer some common questions and give you a general idea of how to approach scheduling your 4th year. For information about specific specialties it's best to meet with a specialty specific advisor and talk with 4th year students going into that specialty.

First, you should know that your 4th year schedule is much more flexible than your 3rd year schedule. So even if you do not get the schedule you want immediately (or don't know what you want), there is a lot of switching that can occur and changes that can be made as the year goes on. It seems like you only have a couple weeks to figure out your schedule, but you will be able to change things later if necessary.

In order to develop a general strategy for scheduling it's nice to have some commonly asked questions answered.

Letters of Recommendation

How many letters of recommendation do I need?
Most programs require three to four letters of recommendation. ERAS will not allow you to send more than four letters of recommendation to any individual program. Therefore, getting four letters of recommendation will be recommended for most people. For some specialties, one of those letters will be a chairman's letter, which means you only need two or three other letters (see below for chairman's letter). You may need more letters of recommendation if you are applying to more than one specialty or you have chosen a specialty where you also have to apply to a transitional or prelim year. In this case, you should get all the letters of recommendation you think you will need. However, remember some letters may work for applying to multiple specialties or for applying to both your categorical and transitional/prelim year (e.g., internal medicine letter). You are allowed to get as many letters of recommendation as you want and upload them onto ERAS. When it is time to send letters to a program, you will just select which of your letters you want to send to each given program. Therefore, you will send a maximum of four letters to each program you apply to, but you can pick from any of the letters you have uploaded to ERAS and you can send different combinations of letters to different programs. Letter writers may submit their letters to the Registrar's Office before the ERAS application opens. They will be kept in your file and uploaded when your ERAS application is available.

From whom should I get letters of recommendation?
In general, you want to get letters of recommendation from someone who has been able to work with you enough to write you a strong letter. Your sub-I rotations or electives early in 4th year are when most people get their letters of recommendation. It is best to plan to get letters during blocks 10-12 (July, August, and September). This will allow enough time for letters to be written then uploaded to ERAS for programs to see them as they begin to offer interviews. In the past, a letter from block 13 (October) could still be helpful depending on when your chosen specialty tends to make most of their interview invitation decisions (some specialties and/or programs are known for waiting for dean's letters ). However, now that dean's letters will come out October 1st, a letter from block 13 may be less helpful. So it will be better and less stressful for you if you get all your letters within the first three blocks. Therefore, you want to plan to schedule your first couple rotations with your need for letters of recommendation in mind (specialty, specific attending, away institution.) Also, keep in mind that you can submit your ERAS application prior to having all of your letters of recommendations (refer to information sessions by the Deans).

Do I have to get letters of recommendation during 3rd year?
No. It is okay if you do not get any letters of recommendation from 3rd year. However, if you do get a letter from 3rd year then that is one less you need 4th year. Keep in mind that you will probably perform better as a 4th year on your rotations than during your 3rd year. So waiting until 4th year may mean your letters will be stronger. Also, attendings expect 4th year students to be requesting letters so you may feel more comfortable asking for one. As a 3rd year, you do not want to ask for letters on each rotation "just in case." 

What is a good letter of recommendation to get 3rd year?
It depends on what specialty you decide to pursue. If you have the opportunity to work with an attending for several weeks or more, this may be a good opportunity to ask for a letter, especially for rotations done at the end of your 3rd year when you are more comfortable and knowledgeable.

What if an attending offers to write me a letter of recommendation?
This is great! The general rule is don't turn down an offer to write a letter of recommendation. There is one caveat though. If you have no or little intention of using the letter, then it's better to not waste a person's time. Thank the person and maybe state that you would appreciate being able to contact them as you approach 4th year and begin to arrange letters of recommendation (just use your judgment).

What is the chairman's letter?
For departments that require chairman's letters, there is a specific faculty member or two in the department who usually writes all these letters. You will usually need to meet briefly with this person so they can get to know you in order to write the letter. Pay attention to any emails sent about specific chairman's letter requirements and deadlines

Interviews

When are interviews?
For most people the majority of interviews will be in November, December, and January. Some programs will start interviewing at the end of October and/or end in early February. Find out from your specialty specific advisor or 4th years which months tend to be the most interview heavy for your specialty. For most people, December is their busiest month. This is a good month to take a vacation block in order to interview.

Do I have to take a vacation block for interviews?
It is often recommended, but depends on the rotations you schedule during interview season, how many interviews you will be doing, and how much traveling you have to do for interviews. Interviewing is fun but will be much more tiring than you anticipate, so having one block as a vacation block to focus on interviewing and catch up on things in between, is very helpful for a lot of people. If you really want to save vacation until the end of the year, you can make it work but you should get advice from 4th years who have done this. If you will be applying to transitional or prelim programs, or if you may be applying to more than one specialty, you will likely be going on many more interviews so scheduling a vacation block during interview season will be important.

What rotations should I schedule during interview season?
Talk with upper years to find out what rotations have a lighter schedule and/or are flexible with interview season. In general, it is best to not schedule your required rotations during interview session. However, interviewing while on your ER rotation is possible since you have flexibility with your shift schedule. Keep in mind that there are Friday lectures and skills sessions for ER that you will need to attend.

Away Rotations

Should I do an away rotation?
There are a couple of reasons to do away rotations but you do NOT have to do any away rotations. Away rotations are often viewed as audition months. It can be an opportunity to rotate at a program you are interested in and show them your interest, have them get to know you, and put your best foot forward. With that said, if you have had some difficulties with your clinical rotations, doing an away rotation may not be the best way to put your best foot forward to a program. You should discuss this with your dean and/or specialty specific advisor. Also, keep in mind that while you are making your first impression, you will be learning a new hospital system, meeting new people and possibly learning a new computer system.

Another reason to consider an away rotation is to have the opportunity to get an up-close look at a program in which you think you are very interested. Interviews are helpful, but you cannot truly know what a program is like without spending time with people in the program. You may find an away rotation helpful for this reason. It may be particularly helpful if you think you will be trying hard to match in a certain limited geographical area such as California or many places in the West.

How do I apply for an away rotation?
Many programs use a central application process called VSAS (Visiting Student Application Service). The registrar's office will need to authorize you for VSAS. If you want to do an away rotation at a college that does not use the VSAS application, you need to visit the college's website to find out how to apply. You will need to get a letter of good standing and possibly a transcript from the registrar's office. You will also need to go to student health to get documentation of your recent PPD results and the lab results proving your immunity to all the standard infections that are vaccinated against.

When do I need to apply for away rotations?
Most deadlines for away rotations will not be until April or May, however refer to VSAS or the college's website for exact deadlines. Since most deadlines are not until the spring, it is okay to wait until you are working on your Jefferson schedule to start deciding on specific away rotations to apply to. It is helpful to have thought about whether or not you want to do an away or multiple away rotations prior to creating your Jefferson schedule so that you can take that into account.

What should I know about scheduling away rotations?
You should know that you might not hear back about away rotations to which you have applied until a couple weeks before the rotation will begin. So you will need to have back-up rotations scheduled through Jefferson in case you do not get the away rotation. Be prepared to be flexible with your schedule because you may need to rearrange rotations in order to accommodate an away rotation. Also, remember that you will likely have to arrange your own housing for the away rotation. Check out the Rotating Room site to see if another student or a resident has a room available to sublet for a month.

What if I haven't chosen a specialty? What do I do?
It's okay! Many students have not chosen a specialty by the time they schedule 4th year and some students may apply to two or more specialties and decide on a specialty at varying times during the application process. It's best to talk with your dean about this, but you may find this general advice helpful.

How should I schedule the beginning of my year?
You probably want to plan to schedule a rotation in each specialty in which you're interested at the beginning of the year. This will allow you to see each specialty again (or for the first time), which may help you make your decision. Then you could consider scheduling your inpatient and/or outpatient sub-I for block 12 and/or block 13. This will help satisfy requirements early in the year and may also help you get another letter of recommendation if necessary.

What about getting letters of recommendation?
All your letters of recommendation do not need to be from your eventual chosen specialty. In fact, a general letter from internal medicine, for example, can be helpful for many specialties. So you may be able to get a letter from 3rd year or a 4th year sub-I that may be helpful for one or both of the specialties in which you are interested. Also, depending on the specialties you are deciding between, a letter from rotations in both specialties may be helpful for both specialties. Also, remember that if it's necessary, you can get extra letters and use different letters for applying to each specialty. ERAS will allow you to select which letters are sent on a program-to-program specific basis so you will have plenty of flexibility.

Miscellaneous Questions

When is the best time to schedule vacation?
Everyone gets two months of vacation 4th year. It is helpful to take a vacation block during interview session. Many people choose to take December off if they take a month off for interviews. Depending on how many interviews you will go on (depending on your chosen specialty), you may not need to take a month of vacation for interviews. If you plan to do this, it will be important to schedule a light elective. Talk to upper year students to find out which electives are good during interview season.

When should I schedule international electives?
The most important thing is to not schedule an international elective during interview session. In general, most people wait until block 17 (end of January-February) or later to schedule international rotations. It may be possible to go internationally earlier in the year, but remember that you will be submitting your ERAS application around September 1st and then you will be scheduling interviews as you get interview invitations in September, October, and November. It's important to have good internet access during this time, as replying quickly to interview invitations is incredibly important. It is also not a good idea to be international during match week just in case you do not match and have to apply via the SOAP process.

In years past determining whether to do an away rotation and how to go about getting an away rotation has been confusing at best. That is why AOA and the Liaison program have teamed up to help you decide whether to do an away rotation and how to find and apply for one. This is by no means comprehensive, but instead a place to start. Along with this primer, your specialty specific advisor and 4th years who have already gone through the process are great resources.

Step 1: Should I do an away rotation?

There are no easy answers, but below are some pros and cons.

Pros:

• A great evaluation or letter of recommendation can help you with a "reach" program.
• A chance to see the country and/or family.
• A chance to try out a program you are considering.
• Can be helpful if you are considering applying in a different region of the country, or want to "try out" a new city.
• A chance to meet residents and attendings at the program (a great way to see if they are "your kind of people" and also nice to see familiar faces on interview day).

Cons:

• Away rotations cost money (ie paying for housing, travel to the rotations, application fee. . .)
• An away rotation is essentially a four week long interview and a bad impression will be detrimental.
• You will have to learn entire new computer system and program set-up.
• When applying you often cannot get your first choice of electives and may have to accept what is left.

Step 2: Ok, I want to do an away rotation. How do I go about finding one?

Start looking early! While some programs do not look at applications until late spring, many programs begin accepting applications in February on a first come, first serve basis. To start you will need a tentative list of programs you are interested in and a sense of how competitive you are at the programs you are considering. Remember a specialty specific advisor, other physicians in the field you are interested in and 4th years applying in that specialty can help in creating a list and determining your competitiveness. Most medical Colleges will have a "visiting students" webpage where you can research an away rotation.

Step 3: How many should I apply to? Should I do more then one away rotation?

There is no easy answer. For most programs if applied to early you will be able to secure a rotation in your specialty though perhaps not in your preferred elective. But keep in mind for more competitive specialties, especially at competitive programs you may not always be accepted and should consider applying to additional programs. As for how many away rotations to do keep in mind your goals for those rotations, the cost and your willingness to "be on the road." Also keep in mind that turning down multiple invitations to rotate could affect your prospect of interviewing at that College.

Step 4: What does an application for an away rotation include?

Every program will have different requirements, but below is a check list to help you organize requirements from each program you are considering.

Away Rotation Check List

• Make an assessment of your finances. About how much will the away rotation cost (application fees, rotation fees, housing, car etc.) Look at the student housing options early.
• Away Rotation Application (generally only 1-2 pages with no essays).
• Proof of Malpractice Insurance Form (can be filled out by the Student Dean’s office).
• Proof of Background check (often required for Pediatric rotations and can be filled out by the Student Dean’s office).
• Annual Physical (Can be done by Employee health).
• Proof of vaccination and vaccine titers (Employee health can fill out forms and draw titers). These vary by medical College - try to get them done very early!!
• Transcripts and proof of course completion (Registrar).
• Letter of recommendation (A physician in the specialty you are interested in).
• Passport Photo (many office supply and office service stores will take the pictures).

Important Final Note

A few years ago, a pilot program was instituted at 10 Colleges to create a universal visiting student online application called VSAS (Visiting Student Application Service). This program has been expanded to over 75 institutions. However, keep in mind some Colleges who participate in VSAS continue to have additional requirements beyond the common VSAS that must be completed in order to be considered. To learn more about Colleges participating and to apply using VSAS please visit the VSAS Web site.