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Getting Prepared for the Wards

This is a very exciting time in medical school.  You are finally making the transition from being a student to becoming a doctor.  Classrooms are no longer the main location of learning, this now shifts to the clinics, and OR, where you will learn from real life patients.  It’s truly a privilege to have this type of access to patients for the purpose of your own learning, and what a necessary experience it is to our medical training.  After the first few days to weeks you may feel scared, and overwhelmed.  Taking care of patients requires medical knowledge, but more than anything, it requires experience, and a thought process to systematically approach a patient as an investigator, based on organ systems.  Once you identify the problem, you must figure out how to treat and help patients get better.  As a third year medical student you will begin to learn the skills necessary to diagnose and treat the sick as a member of a medical team, and the growth continues exponentially through your residency.   By the end of this year, your goal will be to become very comfortable with your white coat, stethoscope, and your basic diagnostic tools (the physical exam, basic diagnostic interpretation, and review of systems questions.)  Intuition, clinical judgment, and treatment will develop as you progress in 4th year, and really become refined during your residency.  This ability will continue to develop through the rest of your career.  Good luck.  This chapter should help you prepare for the wards.  Furthermore, beyond learning, this is a very important year used by residency programs for selection of applicants.  Again, good luck.

How to do well on the wards

READ, READ, and READ SOME MORE.  That is the short, now the long.  Doing well during your clerkships is very important.  Not only will it signify that you have learned a lot, but for the clerkship most respective to your desired residency next year, it will help a great deal for "getting in" if you get honors.  For those already interested in a specific field, this can lead to a lot of pressure.  What I find is that you will do well in the specialty that is right for you, but starting with a game plan will help you do even better.  Another important resource to help make great first impressions on the wards with your team is First Aid for the Wards.  In my opinion this book usually covers all of the pimping questions you will be asked on the wards by your team during the first week.  It is a great starting point, and I would highly recommend reading the respective chapter for your clerkship the weekend before, and then add to it later with whatever reading is required or recommended by the clerkship director.

To do well, you must first understand how your grade is generated.  Most programs rely on the “shelf” exam for clerkships, and how heavily this is weighed in scoring clerkships varies a great deal from school to school.  Furthermore, some schools may incorporate an oral exam.  There are also evaluations, and it is extremely important to know who will be contributing “evals”.  Do they come from residents, if so, most likely the chiefs on your service, but it is important to know if interns also contribute.  You will usually learn the break-down of your grade on the first day of your clerkship during orientation.  Generally it works out that to get “honors” in a clerkship, you have to do well in 3 main areas, knowledge base, responsibility, and enthusiasm/personality.  Lets talk about all of them.

Knowledge base.  I started with this topic because in my opinion it is the most important, and often most objective when it comes time to grading.  You can get evals that suggest the evaluator wants to adopt you into their family, and be 3 hours early every day, but if you do not make the specific cut-offs on the exams, you will not get honors.  Furthermore, the more you read, and the more knowledge you acquire, the more you will shine on the wards when you least expect it.  That being said, keep in mind that as a third year medical student, you can’t know everything, and this is well understood.  What they try to evaluate is your ability to learn, and understand new concepts.

Responsibility.  Don’t make things up if you don’t know.  What I mean is that when you are told to round on patients, look up vitals or check labs, don’t mislead your residents by making up numbers if you forgot to look it up.  Not only will you be putting the patients care in jeopardy by doing this, eventually your residents will find out since they usually re-check everything themselves, and this makes you look a lot worse.  Also, always plan to be early not on time.  Believe me, the more time you have when pre-rounding or writing notes (especially early in the am on surgery rotations), the more thought you can provide and the more organized and complete a progress note you will create.  Consistently being early and prepared is always noticed and goes a far way.

Enthusiasm/Personality.  If you are applying to the field respective to the clerkship or elective you are on in the wards, let your residents know.  This will help you to gain additional and invaluable insight and advice from those in the position you wish to be in the near future.  Also, you will likely be favored, especially if you do a great job.  Another point, try to always be the first there and the last to leave (my brother told me this).  Although things have changed now with the 80 hour work week restrictions, every one picks up on a medical student who is always trying to leave, instead of being forced to leave when they have gone over their hours.  Another point is, always be willing to help out, even with scutt.  No one likes scutt, but it is part of the daily floor work.  Knocking off a task or two off the intern’s to do list is very much so appreciated.  Very often residents are asked to provide feedback on a student’s performance when directors are creating rank lists, and leaving a positive impression will really help.

Setting up your 3rd year clerkships

In some schools you get to decide in what order you will take the core clerkships consisting of Medicine, Surgery, OBGYN, Pediatrics, Psychiatry, Family Medicine.  First thing first, if you know that you want to apply to a residency that involves one of these, and you have a choice, do not take that clerkship first.  If you want to do either Surgery, OBGYN, Pediatrics, Psychiatry, I would recommend having medicine under your belt, and perhaps one other clerkship before taking the clerkship most related to your desired specialty.  The reason is that you can have some experience on the wards, and learn a lot about the physical exam and speaking with patients during medicine. If medicine, or any subspecialty of medicine is your desired career path (subspecialties of medicine usually require a full internal medicine residency first) then try not to take it first.  I would take something not as strenuous as surgery before hand because medicine is usually a long clerkship, and you want to be fresh for it.  The overall main goal is to get as many honors in your clerkships as possible, and especially in the clerkship that most closely relates to your career path.  You will have opportunities to take related electives and build on strong work, but strong work on the core clerkship is required because it is usually the most objective.  What I mean is that it is probably harder to not get honors during an elective than to get honors on a clerkship in many cases, and when applying for residency, program directors know this.

End of 3rd Year, Electives (Away & at Home)

I added this topic here, because you often schedule away rotations months in advance.  When scheduling away electives at a program you are interested in for residency it might not be a bad idea to search the institution’s website if available, and determine in what division of a department the program director, or chair of the department practices medicine in.  For instance, if the program director of a surgery program, is a vascular surgeon in the division of vascular surgery, perhaps try to do an away elective in vascular surgery where you will have an opportunity to work with the program director and their colleagues and perhaps even present a topic during a conference to really show them what your made of.  We will talk later about what to do in preparation for and during your away elective.  Just keep in mind that you can do these anytime up until I would say the end of December before the match (earlier if applying to an early match residency).  This will give you enough time to complete several if desired, have a meaningful experience, make impressions, and get a recommendation letter or grades entered into ERAS in time to be considered by the admissions committee before they create their rank list.  An internal letter by someone respected within the department will carry a lot of weight in your favor if it is excellent.  Sometimes even a conversation between this person and the program director will be more meaningful, and easier to put together.  Also, if you are a person who had average grades in medical school, with excellent grades in classes and clerkship relevant to your desired specialty, I think demonstrating this trend with more courses such as these away electives in your field will be important.  One way to have these noted in your application is to get the grades entered into ERAS.  Keep in mind this can get tricky with outside institutions as it often takes a lot of time because the grade must first enter your school’s system then you have to request another transcript be sent to ERAS.  The other option is requesting an additional letter of recommendation, that can then be added directly to ERAS through your dean’s office.  This is even a good idea for the program to which the faculty member you worked with spoke to the program director.  Reason being, people forget things, especially during casual conversations, and especially program directors who read through all of the final applicant's applications.  This reminder in a form of an official letter will help to put that faculty members positive opinion towards you, to an application, and ultimately to a name and face. 

Getting Ready for the Match 

This is key, because no matter how much you prepare you will never reach your first personal deadline, so plan to arrive early because you don’t want to miss program deadlines.  The main components to your ERAS application are your CV, Personal statement, Transcripts, Letters of recommendation, fees and passport photos.  The application cycle usually starts July 1st for the General Match (earlier for earlier match programs.)  The two components that often lead to the greatest delays are the letters of recommendation, and your personal statement.  The first thing to do is to find out if the specialty you are interested in is part of the ERAS residency application program.  Listed below are the specialties that are eligible (keep in mind that some programs within these specialties still may not use ERAS, so you should definitely verify a programs participation with ERAS by going online (http://www.aamc.org/students/eras/about/start.htm)

Specialties participating in  ERAS (List subject to change):

Anesthesiology

Dermatology

Diagnostic Radiology

Emergency Medicine

Family Practice

General Surgery

Internal Medicine

Internal Medicine-Emergency Medicine

Internal Medicine-Family Practice

Internal Medicine-Pediatrics

Internal Medicine-Physical Medicine & Rehabilitation

Internal Medicine-Psychiatry

Nuclear Medicine

Neurology

Obstetrics and Gynecology

Orthopedic Surgery

Pathology

Pediatrics

Pediatrics/Emergency Medicine

Pediatrics/Physical Medicine & Rehabilitation

Pediatrics/Psychiatry/Child Psychiatry

Physical Medicine & Rehabilitation

Plastic Surgery

PGY1 Psychiatry

Psychiatry - Family Practice

Radiation Oncology

Transitional Year Programs

If some but not all of the programs you wish to apply do not participate in ERAS, then you should print out a copy of your ERAS application, and mail it to the program.  Some programs do not accept printed out ERAS application so then you must factor in the time to complete and submit their individual applications when trying to meet deadlines.

Early Match Residencies: Neurology, Neurosurgery, Ophthalmology, Otolaryngology (ENT), Urology

These specialties are considered early match because rank lists are completed by late December, early January, and applicants are notified by late January.  Even though these specialties are part of the early match, Dean’s letters are still only released on November first.

Here is a time line of the sequence of events for the ERAS application program:

"ERAS 2004 Timeline

Early July

ERAS 2004 Applicant Manuals will be available for PDF download on the ERAS Web site (http://www.aamc.org/students/eras/start.htm)

Early July

Schools may begin to generate and distribute MyERAS tokens to applicants.

Mid July

MyERAS Web site (with limited functionality) will be available. ERAS Post Office is open to schools only.

Early August

AAMC will begin shipping PDWS software and manuals to programs.

Early September

ERAS PostOffice begins transmitting application files from applicants and schools to programs.

November 1st

Dean's Letters are released.

Mid March

NRMP Match results will be available.

May 30

ERAS Post Office will close to prepare for the next application season."

Obviously early match programs work on a different time line!

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