Taking stock of year three: Advice for rising third-years

"The transition from classroom learning to the the clinical years will be the most difficult transition of your careers."

So said one lecturer preparing my class for clinical rotations, one year ago. This sentiment has been echoed by numerous other doctors over the past year. The transition from classroom to clinic represents a fundamental shift in the way that learning takes place, not to mention the additional considerations of teamwork and professionalism. Other major transitions in the medical career (e.g. graduating medical school and becoming an intern, or finishing residency and becoming an attending physician) represent increased responsibility, which is arguably more easy to deal with than a fundamental shift in the way one thinks.

Because of this, I decided that now would be an ideal time to step back, think about all that I have learned over the past year, and pass some of those lessons on to those who will follow me. Keep in mind that that what follows are my own opinions drawn from my own experiences. Other people will have different opinions, and I don't pretend to have all the answers.

1. Attitude. This can be said about anything in life, but I think it's especially true during third-year: A good attitude goes a long way. You are transitioning from learning in a classroom setting to learning in a clinical setting. You will have to figure out how to function well as part of the healthcare team. The reality is that there are many factors outside of your control that will cause you to be a burden on the team. This is more true at the beginning of third year than at the end. Try to minimize your burden on the team, and the best way to do that is to have a good attitude.

• Be happy; if you're not happy, don't show it.
• Be easy and fun to work with, even if you don't like your resident or attending.
• Be excited to learn, even when you're exhausted.
• Take the initiative when caring for patients.
• Take as much responsibility as your resident is willing to give you, even if you feel it's a stretch. If a question starts out with "Do you want to..." then the answer is always "Yes."

2. Perspective. Approach every clerkship as if that will be your specialty for the rest of your career. This may sound silly, or impossible, if you know 100% that you do not want to go into that specialty. But I found that this helped me to maintain a good attitude when I very well could have done otherwise. It's a lot easier to work hard if you feel that what you're doing is important. For that matter, if you absolutely hate a clerkship, remember that it will be over in just a few weeks; just push through it.

3. Study. Treat all of third-year as one long study period for Step 2 Clinical Knowledge. In my opinion, every shelf exam that I took was harder than Step 1. For each shelf exam, start studying early and study frequently, a little bit every day. My general approach to studying:

• Learn from patients. Your patients are your best teachers. Read about your patient's disease on UpToDate: review its pathophysiology, learn different ways that it presents clinically, know its diagnostic criteria and how to treat it. Do a pubmed literature search, if there are any questions related to your patient that can be answered by evidence-based medicine. Then bring back to the team what you find. Information sticks way better when you associate it with one of your patients.
• Pre-Test. This is a specialty-specific series that offers about 500 questions meant to prepare for shelf exams. I only used the surgery, psychiatry, pediatrics, and Ob/Gyn versions. They are all available as real books or as apps on iTunes. I borrowed the book versions of pre-test for psychiatry and pediatrics but decided to splurge for the $30 iTunes apps for surgery and Ob/Gyn. I'm glad I did, too, because there is a lot of waiting around during those two clerkships, so I would just crank out 5-10 questions whenever I had some time to burn. I finished all 500 questions before each respective test. It's important to note that these questions aren't nearly at the level of difficulty as questions on the real exam. In retrospect, I think pre-test would have been helpful for my family medicine departmental exam. I would stay away from pre-test for Internal Medicine, though, because there's MKSAP, a question bank published by the American College of Physicians. 
• Step 2 CK question bank. I bought a year-long subscription to Kaplan's Step 2 CK question bank at the beginning of my surgery clerkship and immediately wished that I had gotten it earlier in third year. I'm told that, like Step 1, Kaplan's Step 2 questions are a little harder than what is on the real test. They worked well for me as a shelf exam study aide. Throughout the clerkship, up until the last week, I did just 5-10 questions every other day or so. Then during the last week I did timed full blocks of 44 questions until I ran out of questions, of course reviewing explanations for every question. If I had extra time, I re-answered questions that I got wrong.
• Specialty-specific textbook. Most clerkships recommended specific text books. The family medicine departmental exam was drawn heavily from Essentials of Family Medicine, which unfortunately is an awful textbook (poorly written, poorly edited, too much emphasis on arcane statistics rather than big picture). The Internal medicine text is Internal Medicine Essentials for Clerkship Students 2 versus Step-Up to Medicine. I chose the first option because it is published by the ACP and is linked to the MKSAP question bank, which I also bought. The surgery departmental exam was drawn heavily from Essentials of General Surgery, which is actually a very well-written book, albeit heavy on text. Ob/Gyn recommended Beckman's Obstetrics and Gynecology, which provided a decent start to studying for the shelf exam. The rest of my clerkships did not recommend any specific textbook.
• Case Files. This is a specialty-specific series that offers case studies as a means of learning the materials. A patient's case is presented, then questions such as the most likely diagnosis or the diagnostic tests to establish the diagnosis or the means of treatment are asked. A short discussion then expands on those learning points. Each chapter is accompanied by a few softball questions that I found relatively useless. The major utility of Case Files, in my opinion, was talking over the cases with classmates. I only used Case Files for neurology and psychiatry, clerkships without a recommended textbook.

4. Practice. Your jobs as a third-year medical student are to learn how to take a good history, do a good physical exam, and present your findings both in notes and oral presentations. This is all easier said than done. If you're on your first clerkship and you think you're good, you're most likely overestimating yourself. Remember that there is always room for improvement. Don't worry if you're slow and clumsy at first; your residents and attendings expect that at the beginning of your third year, but they also expect steady improvement as you move through the year.

• Be methodical about how you collect your patient's history. The conventional order is 1) chief complaint, 2) past medical history, 3) past surgical history, 4) medications, 5) allergies, 6) family history, 7) social history. This will quickly be burned into your mind so deeply that it becomes the way you talk about patients in normal conversation. If it helps, create a template for you to fill in as you're interviewing your patient.
• Sit down when you're talking with patients, even if it means excusing yourself to get a chair or stool. It sets the patient at ease and gives them the impression that you're spending way more time with them than you actually do.
• Figure out how to end patient interviews without being rude or awkward. This is especially important because you'll often be pressed for time.
• Try to do a full physical examination, even if it means coming back to see the patient later when you have more time. Obviously this is not always practical, especially in the clinic where an entire patient visit is only 15-20 minutes. But the more normal exam findings you see, the easier it becomes to recognize an abnormal finding.
• Be proactive about seeing abnormal exam findings, even if it's not on one of your patients.
• Look to the fourth-year medical student notes as good examples to follow. The attendings and residents typically write more abbreviated and utilitarian notes that are not as useful for learning how to write a good note.
• Run your assessment and plan by the intern or resident before presenting a patient on rounds, if possible. This is an opportunity to see if he/she agrees with your plan or wants to change anything, and it helps make you look better in front of your attending.
• Find someone who you can present to as practice, if oral presentations make you nervous. This can be a friend or family member or a significant other. I was fortunate enough to have a resident who taught me how to present, but given how busy residents are, I think this is more the exception than the rule.
• When presenting, fall back on the methodical approach in which you took the patient's history. This will also save you if you're having a nervous brain-freeze. As you progress, you'll figure out how to pick out pertinent positives and negatives that tell the patient's story and guide the listener to your assessment.
• Don't forget to present the patient's vital signs!!! Some attendings want to hear each individual vital sign, but most of the time you can summarize it conversationally: "Patient is afebrile, normotensive, normal heart and respiratory rate, and satting well on room air." Or, more succinctly, "Vital signs stable and within normal limits."

5. Relax. No, seriously, relax. This isn't necessarily the most easy thing for me to do, but over the past year I learned how important it is for me to take full advantage of time off, even if that time is just a post-call day. Spend time with family and friends outside of the medical field, or at the very least try not to talk about medicine-related topics when you're hanging out with medical school friends. Think about what hobbies or activities recharge your batteries, and be proactive about scheduling time to do those. Be aggressive about protecting your relaxation time. Otherwise, you will burn out.