Ted O’Connell, MD
Acing a rotation requires more than just showing up, getting along with your team, demonstrating excellent medical knowledge, and taking great care of your patients. This article provides key information about how to really stand out and make a great impression on your outpatient rotations. How to excel on inpatient rotations will be covered in a separate article.
1. Impress before you even start.
About a week before you start your rotation, email your attending or the rotation coordinator. Ask if they have a schedule available for your review, if they have any prep work they would like you to complete in advance, or if they recommend any reading before the rotation begins. You may also consider asking if they know with which attendings or residents you may be working. If they do have this information, you may want to look those physicians up to get some understanding about their backgrounds and expertise. Even if the answers to these questions is “no,” or they don’t have a schedule prepared in advance, your organizational skills and proactive approach is likely to be noticed and may even be communicated to those in charge of the rotation.
2. Arrive prepared.
Before each half day of clinic, you should ask for a schedule of the day. Arrive early each day and review the medical records of the patients you and your attending or resident will be seeing. If the office is still using paper charts, ask if it may be possible for you to get advance access to these charts so you can review them. Make sure you thoroughly review the medical records and take notes about any pertinent details, including your thought about a plan of action or even routine health screenings that may be due. Your attending or resident is likely to see the pre-work that you have done, which will make a positive impression. It is also appropriate to say “I reviewed our patient’s chart earlier this morning and see that she is here for follow-up of X condition and is also due for a pneumonia vaccine. I’m interested to meet her.” Letting your preceptor know that you have spent time getting to know the day’s patients will score points and maybe even improve the flow of the clinic and quality of patient care.
3. Determine the desired presentation style.
Every attending has a preferred presentation style, and they often differ significantly from one another. Instead of guessing and hoping that you hit the mark, just ask. Does your attending want an entire inpatient-style thorough history that includes the history of present illness, review of systems, past medical history, past surgical history, family history, social history, medical list, and allergies? Or should you just present the medical issue at hand and any pertinent medical history? Being proactive will get you and your preceptor on the same page right away and avoid any frustrations.
4. Offer to write progress notes.
After you determine your preceptor’s desired presentation style, ask if it would be helpful for you to write progress notes for the patients you will be seeing. It takes time out of a busy schedule for your preceptor to have you in the office doing a rotation. Depending on the setting and local regulations, your preceptor may be able to addend and sign your note, saving some time that can be directed to teaching. Even if your attending can’t use your note for official documentation purposes, learning to write good outpatient chart notes is a skill on which you can be provided valuable feedback. Some preceptors will prefer that you focus instead on seeing more patients to get more clinical experience, and that’s great too.
5. Always offer an assessment and plan.
When presenting a patient to your preceptor, you typically will present the subjective information (the “S” in a SOAP note), followed by the vital signs, examination findings, and any relevant data such as laboratory results (the “O” in a SOAP note). At that point, many medical students stop and wait for the attending to say “so what do you think is going on?” or “so what’s your assessment of this patient?” I highly encourage you to go for it and provide your own assessment and plan unsolicited. You may be incorrect or your preceptor may have differing thoughts, but taking the leap and being willing to be wrong does several important things: 1) it shows your attending that you have thought about the patient and are not simply reporting data; 2) it helps your attending understand your thinking and identify knowledge gaps, both of which allow for more focused teaching regarding the medical issue at hand; and 3) it develops your clinical skills because arriving at a well-reasoned assessment and plan is the key sill that every physician must master.
6. Now that you’re committed to providing an assessment and plan, do it expertly.
There are a lot of different ways to present an assessment and plan, and different preceptors may want to hear things differently. This one that I provide will give you a very solid base because it forces you to commit to a diagnosis, it provides a differential diagnosis, you will explain your thinking, and you will commit to a plan for the patient.
Step 1: Briefly summarize the case. “Mrs. Smith is a 74-year-old smoker who presents with exertional chest pain that has been getting worse over the past two weeks.
Step 2: Name your diagnosis and provide support. “I am concerned that Mrs. Smith has unstable angina due to the nature of her chest pain and her multiple cardiac risk factors.”
Step 3: Outline a differential diagnosis (3-4 items will suffice unless your attending asks for more) in descending order of likelihood and your rationale for why these are less likely than your primary diagnosis. “My differential includes pulmonary embolism, pericarditis, pneumothorax, gastroesophageal reflux disease, and musculoskeletal chest wall pain. Her history and exam doesn’t fit these diagnoses as well, and given the seriousness of unstable angina, I think we need to rule that out first.”
Step 4: Provide a treatment plan that supports your diagnosis. “My plan would be to transfer Mrs. Smith to the emergency department for further cardiac workup which should include ECG, chest x-ray, and a full set of labs including cardiac enzymes.”
7. Follow up clinically.
If you and your attending see any interesting cases such as Mrs. Smith, or if you order any studies that requires follow up, you should make a point to follow these patient charts longitudinally to see how the case develops or how the results turn out. Then go follow up with your preceptor to discuss the case. This lets your preceptor know that you cared enough about the patient, that you were interested enough in the case, and take your medical education seriously. You can then go back to your attending and say, “I followed up on Mrs. Smith and see that her ECG and troponins were normal but that she had a positive exercise stress test and underwent cardiac catheterization. I’m glad we sent her to the emergency department.” Your preceptor will be impressed. I guarantee it.
8. Follow up academically.
When seeing patients with your preceptor, make a list of the diagnoses and problems you see as well as any questions you have. When you go home, read up on these conditions. This is one of the best ways to develop a good understanding of a particular medical issue. Then go back to your attending and disucss the finer points of treating a particular issue. You can say, “after seeing Mrs. Smith for chest pain, I did some reading about unstable angina and the treatment of patients after they have been diagnosed with coronary artery disease. Can we talk about how you titrate dosing of beta-blockers and ACE-inhibitors?” Doing so will strengthen your learning and provide your preceptor an opportunity to teach you the finer points of the management of different disease processes.
9. Elicit effective feedback.
May students ask for feedback, as they should. Some attendings and senior residents either naturally provide effective feedback or have been taught to do so. Many others provide feedback that is not particularly helpful or is not very specific and actionable. You can help elicit effective feedback by asking specific questions. Instead of asking, “do you have any feedback for me?” consider your performance and start the question form that point. You could say, “I found it challenging to get Mr. Robinson to give me clear answers to my questions. Do you have any feedback about how I could do that better.” Or you could say, “I struggled with the knee exam on Mr. Robinson. Do you have any feedback about how I could improve my exam?” Or you could say, “I’ve been working on providing a succinct assessment and plan. Do you have any feedback on the assessments and plans I provided for our patients today?”
10. Say “thank you.”
Over the course of your rotation, your preceptor has likely provided you with a lot of clinical experience and teaching. Make a point to say “thank you” at the end of the rotation. You can do this in person, and it often goes a long way to leave a note for your preceptor or sending an email after the rotation has ended. Make it personal and tell your preceptor what you enjoyed about the rotation. If you think the rotation went really well and that your preceptor would be able to write you a strong letter of recommendation, make sure you discuss this with your attending before the rotation ends. This topic is discussed in additional detail in one of my other blog posts.