Third Year Thus Far

Four months into third year at this point, with 2/6 core clerkships down: surgery and psychiatry. I've even knocked off a fourth year specialty (neurology), with another in the queue (orthopedics) - in the interests of more personal/interview time for myself next year.

I'm not gonna revisit the specifics of each rotation I've been through. Instead, I'm going to touch on their similarities.

Studying
Yes, I've harped on and on about how third year's a stark contrast to the first two, in that we aren't buried in books all the time. Key phrase: all the time. Yes, it's still med school and we accordingly still have to study. After all, I couldn't have learned surgery or psychiatry magically. Granted, you learn to some extent in the hospital. But in my experience, the hospital is more of a platform to apply what's been read, reinforce your learning with real patients, and a chance to show attendings and residents what you know. It also lets them get to know you as a person, which I'll touch on later.

At the end of each rotation, there's a "shelf exam." Why the term shelf? No idea. But that clerkship final is referred to as the "shelf." It's national exam of 100 questions given over 130 minutes, with a bajillion answer choices at times. Seriously, the bubble sheets go A-K for some parts. Akin to Step I, it's not just straight up recall. The questions are clinical vignettes reading a paragraph long in which have you integrate a lot of information together and whatever experiences you have. Then, question style can be tricky: secondary or tertiary in nature and/or patient management related. The last option is particularly hard at this point in our careers. Oh and the time crunch is very real and pretty severe, even for the psychiatry shelf. At the halfway point of both shelves so far, I was disconcertingly behind halfway pace.

Bottom of the Pole
As med students, we're at the bottom of the medical hierarchy. Even M4s are senior to us. At this point, we don't even have the luxury of having gone through the core rotations like fourth years have. As such, we're there for purely learning purposes - much like anyone who's not an attending: chief residents, residents, interns, M4s. Unlike those people, our base of knowledge and clinical utility is pretty limited, making us remarkably well suited for scut work - grabbing paperwork, transporting patients, food delivery, etc. Also, since we're new to the scene and rotating through different styles of services, M3s are remarkably awkward for the first few days on service. It's like being a high school freshman again, but having to pay for that experience.

Evals
I already mentioned the shelf exam and what that entails. Of note, it's worth 1/3 of our grade for the rotation. The other 2/3 comes from the attendings, fellows, and senior residents on service with us. Quick summary of what goes into those evals: interpersonal skills, knowledge base, work ethic, professionalism, intellectual curiosity, communication skills, technical skills, etc.

Also of note, comments made in our clerkship evals show up in our med school records. Along with board scores, these third year comments and clerkship scores carry pretty significant weight in residency apps. With all this in mind, being constantly evaluated changes everyone's behavior, to varying degress among different people. Most people don't ask if/when they can leave - even if all our work is finished. Instead, we wait on seniors to give us the ok. Most of my interns and chiefs have been pretty good about letting me go within reason. Others, not so much.

On the other end of the spectrum, there are the ass-kissers. I.e. always volunteering to give a presentation, bringing in journal articles, and just brown-nosing it up. Best thing to do is to not get too annoyed and stay out of their way. Even more annoying and malignant are those who do the above, while also trying to actively outdo/outshine other med students even if it means intentionally making them look bad. There's an understanding among med students that we won't steal others' thunder or try to one up each other in the interests of getting a good eval. Some people obviously don't believe in that mantra.

Work
As I mentioned, M3's primary purpose on the team is to learn. I also touched on how there's some scut work. Outside of that, our work consists of a few basic things we can contribute to the team.
Pre-rounding:
This is basically work that happens before rounding on your service's patients with the team. It'll consist of checking up on overnight changes from nursing and other services. I'll also see if yesterday's orders were followed through on and note any changes in patient conditions. There's follow-up on any biopsies, imaging, and consults that were placed. I'll also see my patients, see how they're doing, and do a brief exam in followup.

Rounding:
We see the service's patients together as a team, usually with the attending. Updates are presented by the med students, residents (who carry more patients, including ours) fill in any gaps we miss, and the attending talks about the patient and elaborates on any teaching points. We see the patient together and then discuss the patient's assessment and plan.

Consults/Admits:
Throughout the rest of the day, we finish up and followup on orders, imaging, and testing ordered on our patients. While all this is happening, your service will get called throughout the day for patient admissions to your service (e.g. recent stroke patient to neurology) or consults from your service (e.g. new onset numbness/weakness in a heart failure patient on the medicine service).

Avg. work day so far: surgery (5AM~6PM), psychiatry (8AM~4PM), neurology (730AM~4PM)
Avg. work week: surgery (75-100 hours), psychiatry/neurology (40-50)

Caveats:
This is the basic framework of a workday. Each service at each hospital with different housestaff will have their variations. The biggest variation comes with the surgical specialties. Prerounding takes place earlier in the day, rounding takes place throughout the day between cases, and consults/admits/floor work are handled between cases or after the operating day is over. OR time makes the work day that much longer, because we still have to medically manage and followup on our patients. That unfortunately makes morning (pre)rounds particularly abrupt and impersonal - there's only so much time that each patient can get in the morning if you have 40-50 patients to see in an hour. Not mentioned are lectures we have to attend and presentations we have to give. These are usually either around lunchtime or during the afternoon. Also not included in the workday are the hours spent studying, prepping for presentations, and reading up on upcoming cases. On last caveat: this all describes a typical inpatient/hospital day. I've yet to be out in the clinics.

So that's basically what a third year rotation looks like. There'll be different flavors depending on if it's medical/surgical, where you're at, and who you work with - but it's all variations on the same theme.