How to Succeed on Rotations: A Guide for Medical Students

by | Jun 30, 2024 | Professional Development

Author: Sneha Polam (OMS III, NSU KPCOM) and Samantha Licciardi (OMS III, ICOM)

Updated: March 24, 2024

Starting clinical rotations can be daunting after spending two years studying from textbooks and lecture slides in preclinical courses. It is completely normal to feel a mix of excitement and nerves as you move from studying in a classroom to practicing in a hospital or clinic. Every month, you will find yourself in a new specialty, facing new challenges, and learning new topics, which can be intense and overwhelming. Recognizing these challenges, we have created a comprehensive guide, including some straightforward tips, to help you navigate your clinical rotations. This guide aims to equip you with practical strategies and advice to help you succeed during this phase of your medical training.

I. How to Succeed on Rotations

– Be engaged and interactive: Show enthusiasm and interest. Take initiative to learn and participate in patient care. Look up potential treatment options, ask about the plan, etc. Be present, attentive, and engaged during rounds, procedures, and any patient interactions.

– Prepare in advance: Review any common conditions or relevant physiology before your rotation. For surgery, there are plenty of YouTube videos on common procedures that you can review beforehand. 

– Ask questions and seek feedback: Don’t hesitate to ask questions but try to make them thoughtful and relevant. It is important to know when it is appropriate to ask questions. Refrain from asking them during busy or critical situations. If you are unsure if it is a good time, feel free to ask your preceptor if they have time for a few questions. Seek feedback from preceptors and residents. 

– Build relationships: Create relationships with your peers, residents, nurses, and attending physicians. Not only will this improve the functioning and quality of the team, but also it will provide you with support and mentorship as you go through your journey in medicine. 

– Most importantly, try to learn one thing from each patient encounter.

– Bring a notebook

On rounds, you will notice there are a lot of things that you may not understand. If you have a small notebook, create a “Things to learn” list that you review after each day. This will not only help you solidify your understanding of new concepts and terminologies but also demonstrate your initiative to learn and grow. Over time, you will see your “Things to learn” list becoming shorter as your knowledge base expands. Additionally, this habit of learning will serve you well throughout your medical career, keeping you curious and engaged. Remember, it’s okay not to know everything right away. What’s important is your commitment to continuous learning and improvement.

*Helpful apps/resources for rotations*

1. MD Calc: Offers clinical decision aids and calculators to help healthcare professionals make informed decisions

– CIWA-Ar: Alcohol withdrawal severity

– Wells’ score for DVT: Risk of DVT

– HEART Score, TIMI Score: Chest pain

– HAS-BLED Score, CHA2DS2-VASc Score: Afib

– LRINEC Score: Necrotizing fasciitis 

– MELD-Na, Childs-Pugh: Liver failure/cirrhosis

– NIH Stroke Scale: Stroke severity score

– PHQ-9: Depression severity; GAD-7: Anxiety

– ABCD2 Score: Risk of stroke after suspected TIA

2. Epocrates: Provides detailed drug information, including dosages, interactions, and side effects

3. USPSTF (U.S. Preventative Services Task Force) Guidelines: Recommendations for preventative healthcare services, guiding clinicians on screenings and preventative practices

4. AMBOSS Knowledge: Offers etiology, clinical features, and management plans for a variety of conditions

5. UWorld/AMBOSS/Anki: Question banks with detailed explanations and flashcard system to reinforce knowledge

6. UpToDate: Offers updated clinical research and guidelines, which are especially helpful when checking treatment recommendations/variations

7. WikiEM: Similar to AMBOSS knowledge 

II. How to Present a Case

1. General Advice

Ask your attendings/residents what their expectations are for presentations

The way attendings like to hear presentations can vary from attending to attending. Asking your attendings what they expect beforehand can help tailor your presentation.

Purchase a History and Physical Examination (H&P) notebook

1. HPI

Start with the patient’s age, past medical history, chief complaint and when it started.

Ex. 55 yo M with PMH of CHF, HTN, HLD presents with bilateral leg swelling onset 3 days ago.

Mnemonics to guide questions (OPQRSTI or OLDCARTS)

 

Think of your differential diagnoses. Use your differentials to guide your questions and rule out certain conditions.

  1. VINDICATE: mnemonic for differentials
    • V: Vascular
    • I: Infectious/Inflammatory
    • N: Neoplastic
    • D: Degenerative/Deficiency
    • I: Intoxication/Idiopathic
    • C: Congenital
    • A: Autoimmune/Allergic
    • T: Trauma
    • E: Endocrine

Chest Pain

  1. ACS (Acute Coronary Syndrome): H/o prior MI, stents
  2. Heart failure: Leg swelling, orthopnea, paroxysmal nocturnal dyspnea, last echocardiogram? Ejection fraction? Fatigue/difficulty performing everyday activities?
  3. GERD: Were you eating anything when the pain started? Similar symptoms with acidic foods like citrus/tomatoes?
  4. Anxiety-related: Occupation? Increased stress at work recently?

Shortness of Breath

  1. COPD: smoking history
  2. Asthma: h/o asthma, inhaler use
  3. PE: Recent long flight/drive, OCP use, leg swelling
  4. Anaphylaxis: Any allergies to medications, foods, or anything in the environment? Do you have an Epipen? 

Syncope/Near Syncope: cardiogenic vs orthostatic vs neurogenic vs vasovagal

  1. Loss of consciousness? Witnessed? Head trauma? 
  2. Stroke/TIA: h/o strokes/TIA, unilateral weakness, facial droop
  3. Seizure: bowel/bladder incontinence, tongue biting, h/o seizures, convulsions, post-ictal state (confusion)
  4. Drug use

Altered Mental Status

  1. What is their baseline?
  2. Orientation: Full name? Where are we right now? What is the month and year?
  3. AEIOU TIPS: mnemonic for AMS differentials
    1. Alcohol (or other drug use): acute intoxication, withdrawal
    2. Epilepsy/Electrolytes: seizure, post-ictal state, abnormal levels of electrolytes
    3. Insulin/Inborn errors of metabolism: hyper or hypoglycemia
    4. Overdose/oxygen: intoxication or withdrawal from drugs, hypoxia/hypercapnia 
    5. Uremia: renal failure
    6. Trauma: concussion or head trauma
    7. Infection: meningitis, encephalitis, sepsis, systemic infections
    8. Psychiatric/Poison: psychosis, depression, mania, exposure to toxins or environmental hazards
    9. Stroke/Subarachnoid hemorrhage/Shock: ischemic or hemorrhagic stroke

Review of Systems: Tailor your questions to rule out differentials

Family History: Cancers, MIs, strokes, DM, HTN, HLD, etc. and what age were they diagnosed

Medications: What medication? Dose? Route (PO, IV, IM, etc.)? How often do you take it/what time of day? When did you start taking it?

Allergies: Any allergies to medications, anything in the environment, any foods? What happens when you’re exposed to it?

Drug use:

  1. Tobacco: Do you currently or have you ever used tobacco products?
    1. If currently using: How long have you been using them for in years? How many packs/cigarettes per day do you smoke?
    2. If quit: How many years ago did you quit? How many years did you use tobacco prior to quitting? How many packs/cigarettes per day did you smoke?
  2. Alcohol: Do you currently or have you ever drink alcohol?
    1. If currently using: How often? For how many years? How beverages per day/week?
    2. If quit: How many years ago did you quit? How many years did you consume alcohol prior to quitting? How many beverages did you drink per day?
  3. Illicit drugs: Any other illicit drug use?

    Vitals

    1. Blood pressure: range in systolic/diastolic (ex. 120s-140s/60s-80s)
    2. Pulse/Heart Rate
    3. Respiratory rate
    4. Temperature: Tmax (ex. Tmax was 38.4)
    5. SaO2: (ex. O2 saturation was 93 on 2L nasal cannula)

    Labs/Physical Exam

    III. SOAP: Used to give an update on an existing patient

    Subjective 

    1. Provide a one-sentence summary of the patient and their main problem

      1. Internal Medicine: 55 yo M with PMH of CHF, HTN, HLD presents for bilateral leg swelling and dyspnea onset 3 days ago, now admitted for management of CHF exacerbation.
      2. Surgery: 55 yo M with PMH of HTN, HLD presents for RUQ pain onset 3 days ago, diagnosed with cholelithiasis complicated by cholecystitis, now day 1 status post cholecystectomy.
    2. Address any overnight events or statements from nurses
    3. Any events on telemetry
    4. Address how the patient is feeling and an update on their symptoms – are they getting better or worse? Are there any new complaints that need to be addressed?

    Objective

    Vitals/Physical Exam

        1. State if the physical exam changed from the day prior and any pertinent physical exam findings
        2. Surgery: always visualize the surgical incision site(s), monitor healing and comment on dressings; Ex. Incision sites are slightly erythematous but no signs of infection; dressing is clean, dry, and intact
          1. Ins/Outs (I/O): check foley outputs/JP drain outputs etc.
      2. Lab trends/New Imaging:
        1. Ex. Hemoglobin trending down. 10.2 yesterday and 8.1 today.

    Assessment

      1. Provide a one-sentence summary of the patient and what they are admitted for.

    Plan

    When creating your plan, ensure you address each problem separately

    Start with the chief complaint and determine potential etiologies 

    How are you addressing this problem?

            1. Medications: What medications is the patient on? Should those medications be adjusted or discontinued? New medications to prescribe? 
            2. Osteopathic manipulative treatment (OMT): Can this patient benefit from OMT and if so, what treatment is most appropriate?
            3. Testing/Therapies: What imaging/lab tests should be ordered? Can the patient benefit from a nutrition consult or physical therapy? Are any tests pending?
            4. Humanistic: Are there any social/emotional/environmental factors that should be addressed?
            5. Education: How can you educate the patient about their diagnosis/treatment options? What information does the patient need to manage their condition effectively?
            6. Referral: Does the patient need a consult from a specialist for further evaluation? 

    Pertinent EKG/Imaging Findings: How are you addressing this problem?

    Pertinent lab/physical exam findings: How are you addressing this problem?

    Any chronic conditions/illnesses: What medications are they on at home and what medications are they receiving in the hospital?

    Creating differential diagnoses: Use the VINDICATE mnemonic; UpToDate/AMBOSS Knowledge can help determine potential etiologies

    Don’t forget to address any recommendations from consultants.

    IV. Tips for Surgery Rotations

    1. Prior to the rotation, review how to scrub, sterile technique, and how to gown. Know your gown and glove sizes. Before surgery, find the scrub tech and ask if they want you to bring it to them. Sometimes, scrub techs will offer to grab your gown and gloves for you.
    2. Before surgery, review the patient’s chart, understand why they are having surgery, and introduce yourself to the patient.
    3. Review the anatomy and watch a YouTube video of the surgery if available to understand the steps.
    4. Help roll the patient in and out of the OR.
    5. You may be asked to help close the trochar sites. You can purchase a suture kit online for practice. Subcuticular interrupted suture: https://www.youtube.com/watch?v=LIRYwERwIxQ&t=571s
    6. Always make sure you eat and drink water before surgery.
    7. Be nice to everyone you encounter and introduce yourself to everyone. Just knowing names can get you far.
    8. Offer to help wherever and whenever you can. At most rotations, they just want to see that you are a good team player and are interested in being there.

    It can be a difficult, yet exciting, transition leaving the classroom and starting to be a part of a healthcare team in a hospital or clinic. Hopefully, this article can facilitate a smooth transition and ease some worries heading into third year. To summarize, it is important to be prepared, engaged, and interactive. It is not expected for you to answer every question correctly, but try to learn from that and get that question right the second time! It will be beneficial to ask about expectations for each rotation and then act toward achieving those expectations. Even though there may be some rotations that do not interest you as a future career, remember that this may be the only time when you can see those procedures or work in that setting, so soak up every opportunity to learn and grow!