Clerkship guide

After successfully completing the basic sciences, students transit from course-based learning to a more practical learning approach in their clinical rotations. In the US and countries with similar 4-year medical programs, classically the first year of this clinical experience includes at least six mandatory rotations known as clerkships and include internal medicine, surgery, pediatrics, OB/GYN, neurology, and psychiatry. Most also include a family medicine clerkship, and in some cases, ambulatory medicine or emergency medicine. Depending on the specialty, clerkship duration varies usually between 4 and 12 weeks. During a clerkship, students become active members of the medical team in a specific field and participate in both inpatient and outpatient care. Under the supervision of preceptors, they obtain first-hand experience in treating patients and gain valuable insight into the routine of practicing physicians. It is a chance to acquire and practice a range of essential clinical skills required for the daily work as a physician, such as rounding, writing notes, placing orders, and presenting patients. Students also learn specialty-specific skills, including basic surgical skills like suturing and knotting, management of pregnancy, and performing specific examinations such as the neurological or mental status examination. Additionally, clerkships are an opportunity for students to explore pre-existing fields of interest and help them determine what they want to practice and specialize in.

The following article covers the general aspects encountered during all clerkships, including pre-rounding, rounding, presenting patients, meetings/conferences, shelf exam info, and study and time management tips. Furthermore, it contains information on professional conduct and evaluation and grading, along with advice on applications to residency. For specific information on the individual clerkships, see the corresponding articles listed in the table below.

Team organization

• Team: The group of physicians and medical students who care for a group of patients. Consists of at least an attending, a senior resident, and an intern.
  • Junior student: Typically a 3^rd- year med student (M3) going through clerkships.
  • Subintern/senior student: Generally an M4 who has already completed core clerkships and doing a sub-internship (sub-I;SI)/advanced clerkship/acting internship (AI). Under guidance from senior residents and attendings, they perform the role of an intern, meaning they have more responsibilities during patient encounters, have more patients, and sometimes help guide M3s. Performance during this experience is often viewed as an “audition” to an outside program.
  • Residents: Physicians in training who are guided by fellows and attendings. Their year in training is indicated by PGY (postgraduate year). So a 4^th-year resident is known as PGY-4. All residents participate in guiding medical students.
    • Intern: A 1^st- year resident, who is either a PGY-1 or PGY-2 who already did a prelim year. Interns are formally guided by fellows and attendings, and informally guided by senior residents. They write most patient notes and informally guide medical students in daily work and patient encounters.
    • Senior resident: Any non-intern resident who leads if a chief or fellow is not on the service. They will do much of the teaching for medical students.
    • Chief resident
      • In most specialties: A resident in the final year who has more administrative and teaching responsibilities.
      • In surgery: The most senior resident on the service.
      • In internal medicine and pediatrics: A resident doing an extra year to gain more experience in administrative and teaching responsibilities. They often work as inpatient attendings in parallel.
  • Fellow: A physician who has already finished residency and is training further in a subspecialty. They may work as inpatient attendings in parallel but still report to a more senior attending as part of the fellowship.
  • Attending: A board-certified physician who completed residency in a specialty. They supervise all team members and are ultimately responsible for patient care.
  • Preceptor: Any supervising instructor (resident or attending) who trains and guides a student's learning experience during the clerkship.
• Chief physician/chair: An attending who works as a senior manager of daily operations and administrative procedures of a department. Sometimes senior attendings will rotate through this role.
• Service: the name of a team combined with the specialty (e.g., Green Surgery; B1 Neurology)
  • There are two main types:
    • Primary services: have primary responsibility for the patient.
    • Consult services: see patients by demand (e.g., daily) of the primary service and make recommendations accordingly
  • There are multiple services for each specialty, often including a mix of primary and consult.

Hospital organization

• Hospital divisions
  • Department: an administrative division of a clinic/hospital
  • Ward: a geographical division of a clinic/hospital, which typically includes patient beds
  • Unit: a functional division of a clinic/hospital
  • For example: The neurology department placed the Stroke Unit in Ward 4, near the Intensive Care Unit.
• Levels of care
  • Transitional Care unit (TCU); also known as Clinical observation unit (COU), Observation (Obs) unit, Clinical decision unit (CDU), Short-stay observation unit (SSOU): A unit typically run by the ED that keeps patients between 6 and 24 hours for conducting triage, diagnostics, treatment, and monitoring, to determine the need for possible admission.
  • General ward/floor: general inpatient ward for patients requiring a lower degree of nursing care
  • Step-down/up unit (SDU); also known as transitional care unit (TCU) or intermediate care unit (IMCU): provide intermediate care for patients between the ICU and general floor
  • Intensive care unit (ICU); often referred to as just “the unit” or sometimes as critical care unit: reserved for critically ill patients and provides the highest degree of nursing care
    • Different departments can have their own ICU (e.g., pediatric ICU, or PICU)
    • Most are closed, meaning the intensivist team takes over primary care.
    • In open ICUs, the original primary service continues caring for the patient

Other important terms and abbreviations

• To staff: to present a patient to a senior team member to get recommendations on management
• To precept: to present a patient in an outpatient setting to a senior team member to get recommendations on management
• Check-out/sign-out: Communicating patient information as a handover between shifts of residents.
• q: every or each (e.g., q2hr = once every 2 hours)

By the week before

• The clerkship coordinator should contact you at least a week before the rotation to provide you with organizational information. If not, you should get in touch to find out who your contact is for the rotation.
• Things you should find out:
  • Where you should be and when on the first day
  • Contact information of your team's senior resident
  • How to get a badge
  • How to get internet and EMR access if possible
  • Any specific dress code (e.g., wearing a full suit)

The first day

• Arrive at least 30 minutes early to give the senior resident plenty of time to connect with you. Call or page them to let them know you are ready whenever.
• Introduce yourself to everyone on the team and other medical staff you encounter.
• Ask what the expectations are for students during the rotation. You can start with a general question, but specifically, you should find out:
  • Who is the attending and specific expectations or pet peeves (e.g., a certain way to present or behave with patients)
  • Daily schedule, including when are rounds, conferences, clinic/surgery days, call schedule
    • Be cautious before asking when you will leave! Doing so may inadvertently indicate a lack of interest.
  • How you can print out the day's list of patients so you are able to print out copies for the whole team every morning in the future.
  • What patient should you follow tomorrow and their intern
• Write down on your list all patients' diagnoses and summaries of their plans to be most prepared.
  • Ask the senior resident if you will be expected to follow any patients that day (e.g., from a night team's check-out).
  • If you are assigned a patient from the night team's check-out, be prepared to present later that day.
• Exchange phone numbers with:
  • Fellow medical students and set up a group chat to easily keep in touch and communicate schedule changes.
  • Residents as you feel comfortable.
  • Add your number to any resident schedules.
• Become familiar with:
  • The printer and fax machines
  • How to dial on the phones and use a pager
  • The EMR and find out how to print a rounding report and resident notes for your patients (e.g., for pre-rounding and preparing a patient presentation)
  • Supply closet locations and organization as well as any codes to enter them, so you can easily prepare supplies as needed in preparation for rounds or procedures afterward.
  • Food options
• Already try to view your nervousness and mistakes as opportunities to grow and something to get used to.
• Until you better understand the culture of the team, consider being conservative with humor. There is always time later to loosen up if this is fitting. If in doubt, remain professional.
• With that said, try to have fun!

Do not be afraid to ask questions about how you can help and improve. The more you ask, the more opportunities you will have!

Examples of common tasks

• Pre-rounding
• Rounding
• Writing notes
• Presenting patients
• Placing tentative orders
• Attending meetings/conferences
• Call duty

Additional information on clinical skills

• For medical history, physical examination, and focused examinations, see:
  • “Pediatric history” and “Pediatric physical examination”
  • “OB/GYN: history and physical examination”
  • “Mental status examination”
  • “Neurological examination”
  • “Head and neck examination”
  • “Examination of lymph nodes” in “Lymphadenopathy”
  • “Pulmonary examination”
  • “Cardiovascular examination”
  • “Abdominal examination”
  • “Skin examination” and “Nail examination” in “Principles of dermatology”
• See “Health care personnel exposures” and “Pre-surgical infection prevention measures” in “Infection prevention and control”.

Overview

• Pre-rounding is the time at the beginning of the hospital day that students spend on gathering patient updates and preparing their case presentations prior to rounding with the team, i.e., with their residents and attendings.
• The objectives for pre-rounding are:
  • Learn what is new with the patient since the last encounter.
  • Perform a focused physical exam to help determine if:
    • Condition/status is stable, improving, or worsening
    • New concerns are developing
  • Gather (not resolve) patient/family concerns and questions that can be addressed during rounds.

Be prepared

• Discuss expectations with your resident and attending beforehand.
• Arrive early to ensure that you have enough time to see your patients and gather all related information before starting formal rounds.
• You can start reviewing the chart the night before to save time.
• Print out a rounding report and the last resident note to have vital information easily accessible.
• Use any additional time before rounds to review the relevant content (e.g., in the AMBOSS library) of the patient's disease such as clinical features, diagnostics, and treatment options.

Study your patient's chart

• Review the admission note, prior progress notes, and rounding report.
  • Key information you should know about your patients:
    • Why are they here?
    • What is keeping them in the hospital?
    • What medical attention do they need for the day?
  • When reading previous notes of patients you will see for the first time, check ER and admission notes. Pay attention to what is already known (e.g., reason for admission, suspected/confirmed diagnoses) and what has already been done (e.g., diagnostic testing, treatments/interventions).
  • Then, review patients' medical records in more depth to obtain:
    • A complete overview of their past medical history
    • Detailed information regarding any underlying medical condition that might play a role during the current hospital admission
  • When checking the notes of a patient who you are already familiar with, focus on new information.
• Look over the vital signs for the last 24 hours and check if they are stable/unstable and if there are any trends.
  • If stable: Note the ranges and last measurement.
  • If unstable: Describe the detected abnormalities
    • Note the measurements before, during, and after the disturbing event.
    • Note what was done to address the unstable vitals and how the patient is doing now.
• Check fluid intake/output (i.e., oral intake, IV administration, and urine collection), diet and bowel movements, and progression of respiratory support (if applicable)
• Review nursing notes and/or have a brief discussion with nurses: They can give you information on details that might not have been charted yet (e.g., bowel movements or acute overnight changes).
• Review notes from consult services
• Review all the prescribed medications: Check if they were given as scheduled or, if prescribed PRN, note how much and how often a patient requested a drug and the amount administered.
• Check laboratory values, noting any differences from baseline.
• Imaging studies: Begin by making your own assessment of the imaging study, and then read the radiology report if available.
• You can discuss with your resident if you should drop a specific patient from your list and/or add another one, which might be justified with:
  • Patients who do not need medical attention and are only waiting to be received by another care center (e.g., rehabilitation hospital)
  • Patients whose management does not suit the learning objectives of the clerkship
  • Patients whose medical care is very complicated and exceeds the scope of a medical student's competencies
  • Patients who pose a threat to your safety
  • Having extra time for more patients
• If agreed upon with a resident or attending to drop a patient from your list, finish your duties before doing so.

See your patient

• You may see patients alone or with a resident depending on the specialty, the specific institution, or preferences of your residents or attendings.
• Before interviewing patients
  • Always prepare questions to ensure that you cover all topics of interest and to minimize improvisation during interviews.
  • Learn who everyone in the room is and do not assume kinship or relations just by appearance or any other apparent factors.
  • If necessary, ask other patients and possibly even family members (depending on patient preference and extent of exam) to leave the room to ensure privacy.
• Take a targeted history.
  • Greet the patient and introduce yourself , e.g., “Hello Mr./Mrs. (patient name), my name is (tell your first name). I’m a medical student with the (name specialty) team/Dr. (name of attending).”
  • Ask about present status and concerns:
    • Start with open-ended questions that allow the patient to freely express their concerns, e.g., “How are you feeling today?”.
    • Use more direct questioning as needed to follow-up on details or uncover further information.
    • Explore and write down details regarding specific concerns.
  • Perform a brief review of systems.
  • Note changes from previous encounters.
• Perform a focused physical examination:
  • General appearance
  • Heart and lung auscultation
  • Abdominal palpation
  • Any other systems that are directly pertinent to the reason for admission
• Addressing questions
  • As a clerkship student, you generally have limited responsibility for the patient's care and you can express that through certain phrasings such as, “Do you have any other questions or concerns that the team can address for you today?” instead of “Is there anything else I can do for you today?”
  • If a patient or present family member/friend asks you questions during the encounter:
    • You should acknowledge and then readdress the responsibility to the team for most questions, e.g. “That’s a good question/I hear your concerns. I will bring it to the team so it can be discussed during rounds later this morning.”
    • You can give answers to simple questions if you feel comfortable and the response does not require further explanations, e.g., “What is the name of the drug?” or “What was my white blood cell count today?”.
• Leaving the room
  • Ask the patient if there are any other questions or concerns
  • Politely conclude the encounter and mention you will return later with the team.

Your main responsibility as a student is to learn, not to make decisions regarding patient management. Redirect everything that goes beyond your responsibility (e.g., questions regarding management from patients or family members) to your preceptors.

Summarize your findings

• Prepare for rounds by quickly writing down the important information gathered from the patient encounter.
• Discuss findings with a senior member of the team who is primarily responsible for the patient, i.e., a sub-intern, intern, or resident.

If there is time

• Practice your patient presentation before rounding starts.
• Read up on patients' conditions, diagnostics, and management steps to be prepared for questions from your attending.
• Start writing your patient note and save it in pending.
• Be a team player:
  • Do not forget to ask fellow clerkship students if they need any help or ask them for help if needed.
  • Asking for help is not a weakness, it is helping patients get the best possible care.

During rounds, clinicians present information about patients to the whole team (i.e., attending, residents, nurses, students, etc.), which allows for discussions with all who are involved in the patients' care. Additionally, rounding offers a great learning opportunity as participants observe colleagues' presentations, see different approaches to patient interactions and management, and discuss questions with the attending.

Overview

• Rounding is often scheduled in the morning to give the residents time to complete the discussed tasks throughout the rest of the day.
• Every patient who is cared for by the team is discussed individually and informed by the team of updates and further management.
• Bedside rounding ^[1]
  • Patient-centered rounds and family-centered rounds: Presentation and discussion of each patient case take place entirely in the patient's room with the patient being the center of the conversation.
  • Traditional rounds: Presentation and discussion of each patient case take place entirely in the patient's room in which the patient is present the whole time but not necessarily the center of attention.
• Rounding in other locations ^[1]
  • Modified traditional rounds (e.g., hallway rounds): Depending on the attendings or the team's preference, some portions of the conversation and discussion may occur outside the patient's room immediately before (or after) seeing the particular patient.
  • Chart rounds (or table rounds): An initial first part of rounding is usually held in an office space to review all charts and discuss all patient cases prior to a second part in which the team sees the patients, explains management plans, and answers questions.
• “Running the list”: After seeing all patients, a summary of the important tasks discussed during rounding is read out by one of the residents to ensure completeness and assign specific responsibilities to the team.

Make the most out of rounds

Pay attention

• Not only is it polite to listen while a colleague is presenting a case, but rounds are also a great learning opportunity.
  • They test and consolidate your knowledge of the diseases that are being discussed.
  • Listen to how residents and other team members present patients and what types of questions the attending asks to be better prepared for your own presentations.
• Try the following tips to stay engaged throughout rounds:
  • Obtain a copy of the team’s patient list and take notes on it.
  • Keep a separate notebook and write down one interesting fact or question that you want to remember for every patient.

Ask questions

• When is a good time to ask questions?
  • Read the room: If the team seems very busy, save your questions for after rounds.
  • Generally, don’t ask questions in front of the patient.
  • When in doubt, you can begin with “I had a question about X, would now be a good time?”
• What should you ask during rounds?
  • Ask for clarification on a topic that you do not fully understand and have already tried to look up.
  • Ask for the reasoning behind a specific management or treatment plan for a patient.
  • Consider avoiding questions of topics you can easily find the answers to. Instead, write them down and try to find the answers yourself during self-directed study time. Ask the team later on if you are unable to find the answers.
  • Questions should not be asked for the sake of asking, but to demonstrate your interest, desire to learn, and that you are paying attention.

Make yourself useful

• Volunteer to help whenever possible: Potential to-dos include calling consult services, preparing supplies (before, during, or after rounds), changing dressings, and translating from languages you know.
• Take notes during rounds on the various tasks that need to be completed for each patient. You might already know which of these tasks fall under the students' responsibility or you can ask a resident if you can take on a specific task from the list.
• Do not be shy to offer your help! Sometimes the only thing you can ask is: “How can I help?”.

Receive feedback

• Receiving regular feedback will:
  • Help you identify which areas to work on and improve your clinical skills quickly
  • Demonstrate that you are insightful and interested in growth and personal development
• Ask for feedback on your presentation and performance during rounds.
  • Do not wait too long after your presentation, so that the residents, attending, and you all still remember your performance.
  • If they are very busy with their own tasks, be considerate and patient.
  • Example: “When it is convenient for you, I would appreciate any feedback on my presentation.”
• If you have identified a specific weakness that you are trying to overcome, ask for advice on that in particular.

Tips and tricks

• Knowing the characteristics of a patient case might prepare you for some questions from the attending.
  • You may be asked questions or even your opinion on a certain treatment or procedure during rounds.
  • In order to anticipate these questions:
    • Ask your interns and residents what they consider important; they are an excellent source of knowledge for patient-specific information and questions from attendings.
    • Observe physician interactions with patients and pay attention to the questions they ask the patients and vice versa.
• Be mindful that where you stand in the room during rounds might affect your learning experience.
  • Try to stay close to both the attending and the patient (without obstructing the conversation) to hear relevant information and observe the bedside manner.
  • Standing near your attending will also increase your chance of being called to volunteer for clinical tasks or procedures.
• Do not have side conversations during rounds.
• Do not interrupt rounds to contradict a senior team member. You can always ask somebody to explain it to you afterward.

General considerations

• Purpose of notes: document what happened and the thought process behind medical decisions
• Notes are usually divided into History and Physical (H&P)/admission notes and progress notes.
  • H&P/admission notes: document the initial clinical encounter with a patient in both inpatient and outpatient settings.
    • In the inpatient setting, this type of note is often called an admission note.
  • Progress notes: generally focus on condition dynamics and record relevant changes
• Notes are usually organized using the SOAP (Subjective, Objective, Assessments, and Plan) format.
• Notes can be created from:
  • Scratch
  • Templates
  • Copy-pasting/copy-forwarding: Previous clinical encounter notes are copied and later edited to reflect the most current information.

You must be careful with copy-pasting notes for future use, as it requires meticulous review and modification of each section to avoid errors and potential breach of patient confidentiality!

• Check-in with your attending to know their expectations regarding the format and amount of details that they would like.
• You can use appropriate abbreviations to write down patients' notes.
• Always forward your note to the resident or attending, ask for feedback, and review any changes made to a note once signed by the preceptor to identify areas of improvement.

SOAP format for writing notes

The SOAP format is a commonly used approach to summarize patient cases. It can be used to structure written notes as well as oral patient presentations (see “Presenting patients” below).

Use the SOAP format (Subjective, Objective, Assessment, Plan) to structure your notes and patient presentations.

Subjective

1. Start with the chief concern: e.g., “The patient is presenting with subacute exertional dyspnea with associated fevers and cough.”
2. Present the patient's history (see medical history for more information):
   • Past medical history
   • Surgical history
   • Family history
   • Social history (including travel history, sexual history, and drug use)
   • Pet exposures
   • Occupational exposures
   • Current medications
   • Allergies
3. Review of systems (ROS)
   • For newly seen patients, include a detailed ROS containing some or all of the following:
     • Head, Neck, Eyes, Ears, Throat: headaches, neck stiffness, blurred vision, tinnitus, sore throat
     • Cardiac: chest pain, palpitations, orthopnea, edema
     • Pulmonary: cough, sputum production, hemoptysis, dyspnea
     • Gastrointestinal: abdominal pain, constipation, diarrhea, melena
     • Urinary: hematuria, dysuria, frequency, urgency
     • Musculoskeletal: arthralgias, back pain, myalgias
     • Skin: color, rash, dryness
     • Neurological: weakness, numbness, confusion, somnolence
   • For daily progress notes, include a review of relevant systems if there were any changes.

Objective

• Start with vital signs (including oxygenation when appropriate).
• In emergency settings, list ventilator settings, monitor readings, fluid balance, drain outputs, and other relevant measures.
• General appearance
• Pertinent physical examination findings (see physical examination for more details)
• Labs: Usually blood tests are presented first, followed by other laboratory tests. Focus particularly on trends and changes from baseline.
• Imaging: X-rays are followed by more complex investigations, such as CT and MRI.
• Other diagnostic measures: ECG, EEG, etc.

Assessment

Where the patient's likely problems and their etiologies are summarized, starting with the most likely problem/probable diagnosis, based on interpretations of subjective and objective findings so far.

• If a working diagnosis/problem has not been established or new information warrants an adjustment:
  • State the probable diagnosis and possible etiologies based on the patient's data so far.
  • List the likely differential diagnoses.
• If the working diagnosis has already been established without the need for modifications: Comment on the status of the patient's condition, i.e., whether it is improving, worsening, or stable.

Plan

• Outline the next steps in the patient's management.
• List each of the patient's problems separately and explain what is intended to:
  • Diagnose a disease: Consider testing that supports or rules out a differential diagnosis (e.g., diagnostic imaging, labs, ECG).
  • Treat the patient, including:
    • Specific treatments for diseases (e.g., antihypertensives, antibiotics, immunosuppressants)
    • Management plans for current symptoms or concerns (e.g., pain management, thrombosis prophylaxis)
• If a patient has various problems:
  • Rank them according to their severity and acuity
  • Group conditions based on associations and address similar topics together.

Tip: If feasible, look at the previous day's plan to help determine today's plan. In many cases, it will not change.

Tips and tricks

• Ask your attending or resident:
  • If they want you to use a specific template for your notes
  • How you should submit your notes (e.g., by entering them in the patient chart or EMR, by sending them to your preceptor for review and comments)
• Save templates that you receive from your preceptors or create yourself to save time in the future.
• Avoid excessive jargon and too many abbreviations.
• Take your time while writing notes at first, as it is important that your notes are comprehensive and well-structured. You will become faster with time and practice.

Example of a daily progress note

• Subjective: No acute events O/N . Pt. noted no n/v , no d/c ; reports mild RUQ pain.
• Objective:
  • VS:
    • T: 37.2
    • P: 84
    • BP: 124/82
    • RR: 19
    • Gen: NAD, resting comfortably in bed
    • CV: RRR, normal S1 and S2, no S3, S4, no m/r/g
    • Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi
    • Abd: soft, mild tenderness in RUQ, +BSx4 quadrants, no masses palpable, no organomegaly; post-op wounds clean
    • Skin: no rashes, lesions, petechiae
    • Ext: 2+ pedal pulses bilaterally, no c/c/e
• Assessment: The patient is a 42-year-old woman on postoperative day 1 for laparoscopic cholecystectomy. Improving well.
• Plan: Advance diet. Follow-up with abdominal US. Monitor CBC, electrolytes, BUN, and creatinine daily.

Never forget to add the date, time, and signature to all your notes and orders!

Your note is proof of your work. If it is not in a note, it did not happen.

SOAP format for patient presentation

The general presentation structure follows the same SOAP (Subjective, Objective, Assessments, and Plan) format as patient notes. (See “Writing notes” above for more information.)

Subjective

• Use a one-liner to give a short overview statement which includes the following information:
  • Identifying information (age, gender, race)
  • Risk factors
  • Relevant past medical history
  • Presenting symptoms and chief concern
  • Example: “Mr. X is a 69-year-old white man with a past medical history of hypertension and type 2 diabetes who presented to the hospital yesterday with acute onset of retrosternal chest pain and dyspnea.”
• History: Discuss interval changes in history and mental status, e.g., “The patient reports mood improvement.” (See medical history for mnemonics to use for quickly covering the important points of the history.)
• Review of systems (ROS): Only include the pertinent positive and negative symptoms.

Objective

• General appearance
• Abnormal vital signs
• Pertinent physical exam
• New medications or how often PRN medication was administered.
• Relevant lab values, imaging, and other diagnostic findings, focusing especially on any trends or changes from baseline

Assessment

• Assessment statement
  • This is a very important skill to learn as it shows your ability to synthesize the most important pieces of information from the history, physical exam, and diagnostic findings into one coherent sentence and formulate a working diagnosis. It is similar to the chief concern but includes info such as:
    • Further details regarding the chief concern (e.g., frequency, mild/moderate/severe severity, acute/chronic onset)
    • Associated factors or symptoms (e.g., triggering events, additional symptoms of the same or a closely related organ system)
    • Risk factors (e.g., relevant comorbidities, risky behaviors)
    • Additional relevant findings (e.g., crucial imaging, lab, or other test results) and their significance
  • Example: “Mr. X is a 69-year-old man with a past medical history of hypertension and type 2 diabetes who presented to the hospital yesterday with acute onset of severe retrosternal chest pain and dyspnea after exertion for the first time. The laboratory evaluation did not reveal elevated cardiac markers and the ECG showed no ST elevations or other signs of cardiac ischemia. The patient's symptoms are most consistent with unstable angina.”
• Differential diagnoses: Make sure to rank from most likely, can’t miss, to less likely diagnoses.

Plan

• Outline your next steps in the management of the patient (e.g., diagnostic imaging, labs, medications, consults, and disposition )

When presenting the ROS, do not include too much detailed information (especially negative findings) because you will waste valuable time and most likely lose your preceptors' attention.

If feasible, look at the previous day's plan to help determine today's plan. In many cases, it will not change.

Tips and tricks

Presenting a patient might feel overwhelming at first. Here are some tips to help gain more confidence and make things less confusing:

• Ask the senior resident or attending for their preferred presentation format. Different attendings have different expectations!
• Directly after pre-rounding, prepare an outline of the presentation before you forget the patient's information that you just gathered.
• Practice!
  • Ask the intern and senior resident if you can practice with them before presenting to the rest of the team.
  • Practicing in front of a mirror or with a friend can help you become familiar with the case that you are presenting, test the way that you are phrasing certain findings, and be more confident during the presentation with the team.
• Aim for giving a free presentation to show understanding and mastery. Do not just read off your notes!
• Speak with confidence during your presentation.
• Use the pronoun “we” to capture the teamwork involved in patient care.
• Be prepared to be asked additional questions on the topic that you are presenting: Make sure you know the pathophysiology, clinical features, diagnostics, and treatment of the condition your patient presents with.
• No decisions will be made based solely on your assessment. Remember that an intern is also assigned to your patient. As a medical student, you are there to practice and learn.

It is perfectly normal to be especially nervous the first few times you present a patient, but there is no need to worry! Everyone has had to start somewhere and knows what you are going through.

Presenting a patient in the outpatient setting

• Preparation
  • Summarize the main points from the patient's chart, including documenting the patient’s last clinic visit.
  • Take notes while you are seeing the patient, focusing on the reason for the current visit and progress since the last one.
  • Write down your thoughts right after the patient visit.
• Presentation
  • Start the presentation with a chief concern followed by the summary statement.
  • Use the notes to go through each problem systematically.
  • Describe the patient's physical exam, starting with vitals and followed by pertinent positive and negative findings.
  • Conclude the presentation: Give a brief assessment and plan regarding today’s encounter similar to formatting an inpatient assessment and plan (see above).
  • Example of assessment and plan for a patient presenting with abdominal pain and a history of coronary artery disease:
    • Start with your differential diagnosis regarding the chief complaint, i.e., abdominal pain.
    • Present diagnostics and treatment options for the patient.
    • Move on to the patient's chronic issues such as coronary artery disease: List the current medications, whether the patient has received any new treatment since the last visit, and whether any changes should be made.

Depending on the institution, the team, and the medical student’s level of comfort, medical students have varying degrees of involvement in the placement of orders. Unlike the residents’ orders, medical students’ orders are generally invalid (pended) until signed off by a resident or attending. Exact methods for placing orders also vary based on the electronic medical record (EMR) system used by an institution.

How to place an order

• Medications
  • All medication orders require a dosage, route, frequency, start time, end time (can be “until discontinued” or “until X doses have been given”), and priority (stat , ASAP, or routine).
  • Some medications can be ordered PRN ahead of time so nurses can administer them when necessary (e.g., acetaminophen can be ordered PRN so that is can be administered immediately if the patient spikes a fever overnight – this can save time, sleep, and a phone call.)
• Consults
  • Must be formally ordered for billing purposes
  • Often the consulting team has already been called in advance as this usually decreases the response time and a consult visit can already be scheduled.
  • If you are asked to place an order for a consult, place the electronic order and ask if the team has been called already or if you should contact them.
• Imaging
  • Similar to consult requests, imaging orders often need to be followed up with a phone call. Call the hospital’s imaging lab to schedule an appointment for your patient.
  • If time-sensitive, you might even call in advance and place the official order afterward.
• Admission orders: any orders pertaining to the patient’s hospital admission, including patient room, bed, isolation or contact precautions, medications to continue from home/ER, procedures/imaging/tests to be scheduled, code status, schedules when nurses should take vitals, restraints, and diet orders
• Discharge orders: any orders necessary for the patient management after discharge, including home-care instructions, any wheelchairs/crutches/other home care equipment, wound dressings, follow-up visits with a primary care provider or specialist, and medications from the hospital that should be continued or discontinued

If I am not allowed to place orders

Even if you are not allowed to place orders as a medical student, you can still help:

• Make phone calls and follow up on consults or imaging/labs.
• Keep an overview of all the orders that are needed for the patients on the team and check if everything has been entered into the EMR system correctly.
• Observing residents placing orders or placing orders with them can be a great learning opportunity. Offer your suggestions for specific orders and ask questions!
• Write down the orders you would place and ask your preceptor if they agree or what they decided to enter into the system.

When a medical student is “on-call” it means that they will spend the night with their clinical team, caring for the previously admitted patients and admitting new patients that present to the emergency department. Students may be required to complete a certain number of duty hours during call shifts per clerkship. However, tasks and responsibilities vary depending on the specialty, institution, attendings, and residents.

Call schedule

• Your call schedule might match one of your residents' call schedules, which will allow you to develop a routine during your rotation.
• Common frequencies for being “on-call” range from once every 4 to 7 days (described as 24q4 or 24q7), although many clerkships only require one or two such experiences for medical students, if any at all.
• Students will usually be allowed to end their shifts after completing their notes and signing out their patients to the day team. While these students are generally excused from all in-hospital duties on the day following their shift, some programs might still require them to attend educational activities in the afternoon.
• Occasionally, rather than participating in a traditional overnight call, students may only be required to stay at the hospital until the completion of overnight rounds (often at 11 p.m. or midnight). However, students might then not be excused from the in-hospital activities on the day following their shift.

Objectives and responsibilities

• Gain experience diagnosing and managing patients outside normal working hours
• Observing the duties and responsibilities of interns and residents during call shifts can offer a full picture of what is expected in a specialty.
• Occasionally, you may be required to handle a pager.
• You are expected to participate in sign-outs/check-outs (from and to the day team) as well as night rounds.
• Examples of specific student tasks:
  • Attend consults and see new patients in the emergency department with the resident.
  • Follow up on laboratory values and imaging results.
  • Participate in codes as a member of the clinical team.
  • Assist with urgent procedures (e.g., central catheter placement, lumbar puncture).
  • During surgical rotations, students might have the chance to assist with or observe emergency surgeries that occur overnight.

Tips

• The first time you are “on-call” can be a stressful experience and you may find yourself struggling with basic tasks. Don't be afraid to ask the resident for help!
• Pack an overnight kit that contains study materials, snacks, chargers, and a toothbrush.
• Use breaks during the night to stay hydrated, eat, and take naps whenever you can.
• Be prepared for a decrease in attention span: Double-check your notes and calculations and, when in doubt, always ask your resident!
• Ask questions during night rounds: Fewer people are present, making this an ideal time for you to discuss topics that the team might not have the time for during the day.
• If you receive a phone call about a patient: Make sure to write down all the important information and inform your resident!
  • In case of an emergency, inform your resident immediately!
  • If not an emergency, open the sign-out notes, and the patient's chart and take notes of what the caller (e.g., a nurse) tells you about the patient (e.g., new problem, lab results, imaging findings).
  • Ask additional questions if necessary (e.g., “Does the patient have stable vitals?”, “What has been done so far?”, “What does the nurse suggest doing?”)
  • Review the information with your resident.
  • Go to the patient's bedside with the resident.
• If you have free time during the night, you can use it to:
  • Study for the shelf exam or step 2/level 2.
  • Observe and learn from other members of the healthcare team including nurses and advanced practice providers.
  • Ask for additional tips and feedback from the residents.

Types of conferences and meetings

• Daily teaching rounds
  • Include morning reports and noon conferences, which are basically resident seminars and case presentations.
  • You may be asked to present a topic depending on your rotation requirements.
• Clinical topics lectures
  • Generally given by residents or attendings
  • Focus on conditions and clinical scenarios in the respective field and how to approach them
• Grand rounds
  • Typically occur once weekly with all faculty and staff present (including chiefs, attendings, residents, and medical students)
  • An inpatient conference involving the presentation of a patient’s medical problems and management, which is followed by a discussion among all present
  • Food is usually present!
• Morbidity and Mortality (M&M) conferences
  • Cases involving adverse outcomes are confidentially presented and discussed among peers, with a focus on identifying potential medical errors and how they could be avoided in the future.
  • May occur on a set day of the week or month with all faculty and staff present
• Core curriculum didactic activities
  • Include lectures, case-based sessions, and seminars
  • Vary according to departmental and institutional requirements

Tips and tricks

• Some programs may ask you to present a case. If you have interesting patients, remember who they are and how to find them in the medical records so you can create a presentation about the topic when needed in the future.
• While you may be tempted to study for your shelf exam during a conference, try to focus on the presented material. It is not uncommon for attendings to ask you about the content that was discussed at the conferences.
• Try to come up with 1–2 specific points from each lecture (these might be facts that you want to commit to memory or some interesting discussion points).
• If residents are giving presentations, they sometimes like to call on medical students. Make sure to pay attention and be prepared to participate!

Patient data confidentiality and discretion

• General
  • During the clinical clerkship, you are a part of a medical team that cares for patients. Accordingly, you also have all the legal and ethical obligations regarding the security and confidentiality of patient records.
  • Besides its legal aspect, confidentiality is one of the key components of the doctor-patient relationship.
• Discretion
  • Information about a patient should only be available for people who are directly involved in the patient's care.
  • Do not give out information to any other people without the patient's explicit permission, not even if they are immediate relatives.
  • If somebody approaches you with patient-related queries and you are not sure if you are allowed to give out the desired information, redirect to your attending.
  • Avoid discussing patient cases in crowded places within the hospital (e.g., the elevator or cafeteria) even if you are not using the patient's name.
  • Remember to log out of the electronic medical record (EMR) system when you leave the computer so no unauthorized person can have access.
• Documenting patient data
  • Most of the medical information is kept in the EMR system and can be accessed from computers at medical facilities.
    • Whether or not students get personal access to the EMR depends on the hospital and the program.
    • If you do have access, carefully read all hospital policies regarding EMR use and make sure you know how to use the system before you start working with it.
  • In many institutions, paper charts are also used still
    • Paper charts pose a greater risk of information getting lost or spread to unauthorized persons.
    • Never leave your notes lying around! Forgetting them somewhere can cause a substantial breach in patients' confidentiality.
• Respecting patient autonomy and privacy
  • Explain procedures and examinations to the patient.
  • If the patient is not in a private room, pull the curtains around the bed before starting the examination.
  • Before removing blankets or garments, explain the need and ask the patient if they are OK with it.
• For more information: See “Medical ethics” and “Confidentiality” in principles of medical law and ethics.

Dress code

The dress code at your hospital might be different from what is stated below. If you are uncertain, ask a member of your team.

• General
  • Always wear your name tag.
  • Put on a closed white coat for all patient encounters.
  • Most institutions require that tattoos are covered and do not allow facial piercings.
  • If you have long hair, have a hair tie and pull your hair back while seeing patients.
• Professional attire: Wear professional attire during rounds, conferences, and when working in the outpatient clinic or in an ambulatory setting.
• Scrubs
  • In the operating room, you have to wear scrubs and additional garments, such as surgical shoe covers, a mask, and a surgical cap.
  • On surgery/procedural days, wearing scrubs covered by a closed white coat is usually allowed when going back to the wards.
  • Do not wear scrubs outside of the hospital unless your hospital's policy allows it.

Professional behavior

• Addressing physicians
  • Call all physicians “Doctor [last name]” until told by them otherwise.
  • Almost all residents and most fellows will just ask you to refer to them by their first name.
  • Despite what others in the team may do, continue to refer to attendings as “Doctor [last name]” unless they explicitly ask you to refer to them by first name.
• Be respectful and respected
  • Introduce yourself, including identifying yourself as a student, before asking someone a question or calling a consult.
  • Learn and use the names of all the nurses and other staff in the ward
  • Be polite to the nurses and other staff and show appreciation for their work.
  • Do not talk poorly about patients even when they are unconscious or sedated.
  • Never talk bad about your institution or colleagues while in the hospital. In addition to creating negative feelings, there is always a chance of being overheard.
  • Do not lie if you forgot to do something, such as history taking or a physical exam. Be honest and offer to still make up for it if possible.
  • Talk at a reasonable noise level. Although you should avoid being too loud or too quiet, you do not have to apologize for breathing!
  • Be humble and do not take things personally. Working in the hospital can be stressful for everyone and sometimes the tension leads to rough communication.
  • Although you should be humble and respectful, do not feel overly intimidated or let people abuse you!
• Be enthusiastic and engaged
  • Always arrive in advance and do not leave early unless told otherwise.
    • If you need to leave, it is best to always confirm with the senior resident.
  • Ask questions and volunteer for all tasks that are within your capacity.
    • Wait until watching a process a few times before asking to help uninvited, so that you do not take on more than you are ready for.
  • Do not start studying if there is still clinical work to be done.
• Practice professional communication
  • Do not start a discussion with team members in front of a patient. If you strongly disagree with something, you can address your concerns outside of the patient room.
  • Do not interrupt rounds or surgery/procedure to contradict a senior. You can always ask a team member to explain it to you afterward.
  • Do not have side conversations during rounds or during surgery/procedures. You can always bring a topic up or ask questions later - make a note if you need to.
  • Compose yourself when encountering patients. You do not want to walk into a patient's room laughing, and then have to give bad news.
  • To minimize disruption, phones and pagers should be on vibration. Do not be on the phone while conducting clinical tasks unless asked to find out some information.

Know your patient best

• You should know your patient so well, that you are the one informing your team of updates and not the other way around. (Unless, of course, the update is first communicated to a resident by phone.)

Clerkships are the best time for you to get hands-on experience in each of the clinical specialties. Whether or not you enter your 3^rd year with a firm decision of which specialty would you like to pursue, clinical experience during clerkships will help you make or support this decision accordingly. It is important to make a decision as early as possible to begin preparing your application to match successfully.

See the article “Residency applications” for more information on how to best prepare during clerkships, including recommendations for letters of recommendation (LORs) and gathering research experience.

Grading structure

• At most institutions, the overall clerkship performance is evaluated by giving students a final grade.
• The determinants of this final clerkship grade vary both by school and clerkship but usually comprise the following:
  • Clinical grade
    • Determined by preceptor evaluations from attendings, residents, and/or interns.
    • Evaluators base their grades on the student's ability to complete tasks such as patient presentations, H&Ps, patient notes, admission orders, and clinical logs.
    • Written evaluations often consist of numerical scores across a range of topics that may include clinical knowledge, clinical reasoning, bedside manner, and teamwork abilities.
    • In many cases, performance evaluations also contain written comments that may provide clerkship directors with more information about the student's performance.
  • Examination grade
    • Determined by performance in the shelf exam (NBME for MD students; NBOME for DO students)
    • Some institutions have in-house exams and evaluations (e.g., mid-clerkship written exams, graded case presentations at conferences, weekly quizzes), sometimes in addition to a shelf exam, and standardized patient experiences (OSCE).
  • Final projects: Programs may also have graded final projects for the clerkship such as a case report or lecture on a patient's rare disease/presentation.

Grading scale

• For students attending medical schools without a pass-fail grading system, students are usually graded on a relative scale.
• A typical clerkship grading scale may be:
  • Honors: top 15–20% performing students
  • High pass: middle 25–30% performing students
  • Pass: lower 50% performing students
  • In some cases, there are additional grades such as:
    • Marginal pass: rare grade, borderline failing
    • Fail: usually requires a student to have committed a professionalism violation and/or failed a clerkship/shelf exam without successful remediation

Impact of the grade

• In addition to other factors, grades that students receive during their clerkship period are criteria by which program directors assess the fitness of a candidate for a residency position.
• Clerkship grades may also be a factor in determining whether someone qualifies for honors societies (e.g., AOA ).

Committed learning

• Continuously read
  • On your first day, ask the attending about their preferred resources.
  • Attendings can usually tell who has been reading and keeping up with various topics on the rotation.
  • Sometimes, attendings will explicitly ask you to read about a specific topic; this should then be a top priority.
  • Try to find out what patient cases you will encounter the next day to guide your reading the night before.
• Ask thoughtful questions
  • Before approaching your attending with a question, read about the topic and see if you can quickly find the answer yourself.
  • Attendings are usually happy to help you understand a topic better and answer clarifying questions, especially after you have shown you studied the basics.
• Put effort into presentations
  • If you are assigned a presentation by an attending, put in your best work.
  • Your attendings will take notice and give you a better evaluation even if the presentation itself might not be graded.
  • Spend extra time reading current publications and reference the latest data.

Oral questioning by attendings and residents (typically referred to as “pimping”)

• General
  • Throughout their clerkships, students will repeatedly be quizzed by their attendings.
  • These questioning sessions can take place at any time of the day and may be unannounced.
  • Even though many students have mixed feelings regarding being quizzed, ultimately, physicians are taking time out of their very busy days to teach you at a personal level.
  • So try to view these sessions as opportunities for intense learning and to “show off” what you know and impress your preceptor.
• Approaches: Depending on your attending's personal preferences, the questioning sessions can be more classic or contemporary, as well as formal or informal.
  • Contemporary: The preceptor asks questions tailored to encourage critical thinking based on the trainee's understanding and knowledge gaps, typically using the Socratic method.
  • Classic: The preceptor asks trainees questions he/she already knows the answer to in rapid succession with increasingly harder questions until the trainee can no longer answer, thereby reinforcing the hierarchy.
  • Formal: Questioning sessions typically cover topics that are based on the school/clerkship curriculum or the shelf exam. They are often a set part of rounds in between patient encounters or while conducting procedures.
  • Informal: Questioning sessions are often centered around patient care or advanced information, and occur in random, shorter time periods as part of normal discussions.
• Topics: Most attendings have their favorite topics and/or a set of questions that they frequently ask.
  • Residents and interns can provide helpful insights into an attending's preferences.
  • After a questioning session (or after the attending has talked about a topic), write down everything you remember and review it at home.
    • Pay attention to questions asked of both you and your colleagues.
    • It is not uncommon to be asked the same question several times during your clerkship.

Tip: Add personal notes and attending questions to sections of relevant AMBOSS articles for quick retrieval and review!

• Shelf exam preparation: Starting early with shelf exam studying will not only help you achieve higher scores in the exam but will also prepare you for attending questioning.

Study your patients

A large part of the attending's questions will revolve around the patients you follow, so you should know everything about them.

• Review the chart: Be aware of all relevant findings concerning history, physical examination, and laboratory studies.
• Plan for the day
  • Especially at the beginning of the rotation, discuss your patient plan with the intern or resident before rounding.
  • Always be prepared to give your opinion on what the next steps should be for your patient. .
  • If you propose to start a new medication or treatment, read up on its supporting evidence, including knowing details of the key guidelines and studies, so you can confidently explain your suggestion.

For many attendings, knowing where the information came from is just as important as knowing the information itself!

• Review pharmacology
  • Read up on common adverse effects and potential medication interactions.
  • Be aware of patient allergies and the type of reaction they experienced.
• Know the basics: Read essentials about your patient's condition or working diagnosis.

When you do not know the answer

• Try to avoid saying “I don't know.” Instead:
  • Try summarizing small logical steps based on what you do know, even if “common sense.”
  • You can also rule out/mention associated things that the answer is not.
  • Follow-up questions may then help guide you further to being able to fully answer the question or make a more educated guess.
• Be honest if you have no idea.
  • Do not make things up or blindly guess.
  • Admit that you do not know the answer. Attendings will appreciate your honesty and attempt to save time by not guessing.
• Do not get flustered.
  • You are not expected to know everything since much of the learning will occur during rounds (especially as a student).
  • Remember that ultimately, you're there to learn how to become a better doctor, not to get all the questions right.
• Prepare for the next time.
  • Chances are that you will be asked the same question the next day.
  • Show your willingness to learn by telling your attending you will look up the answer and get back to them.

If you got a question wrong once, be prepared to be asked the same question again.

• Seize the learning opportunity.
  • We learn best from our mistakes so treat each unanswered question as a learning opportunity.
  • These questions make will make you aware of what you don't know and can help to direct self-study time.

Do not be hard on yourself if you answered some attending questions incorrectly. Remember that you are a student and these questions are an opportunity for you to learn. Expressing your interest to learn is most important!

Interpersonal skills

• Establish a relationship with your attending
  • Most attendings are kind and will encourage you to be the best clinician you can be.
  • However, there will be a few that might be great clinically but have a bad record when it comes to working with students.
    • Before you start a rotation, ask your seniors or classmates which attendings are known to be fair and best to work with.
    • If you are assigned to an attending who has a poor reputation, the first step is not to panic. Be confident and show up with your best attitude.
    • Remember that you will only be working with an attending for a brief period of time.
  • Although being genuine usually makes it easier to impress your attendings, do not exhibit behavior that annoys them or gives them the impression you do not want to learn.
  • Ask your attendings (and residents) for feedback every week and take it in a positive manner, even if you might not fully agree at that moment.
    • Asking for feedback will not only show them that you care for their opinion, but it will also help you become a better doctor.
    • When you receive criticism, show that you are working on it. Your attendings and residents want you to succeed!
• Truly care for your patients
  • Being able to build a rapport with patients is one of the most important qualities of a good doctor.
  • Show your preceptors that you are genuinely concerned about your patients.
  • Always be up-to-date on things related to your patients.
    • Arrive early enough to allow yourself plenty of time for pre-rounding of your patients.
    • Follow up on your patients’ labs, consult team recommendations, and imaging diligently.
• Be a team player
  • Modern medicine is a team effort, and for many attendings, a student's behavior in a group setting is even more important than their medical knowledge.
  • If you see yourself as an integral member of the team, so will your colleagues.
  • Take initiative and volunteer for all tasks that are within your capacity. Doing what you can to help your team will reflect very well on you.
  • Carry a good attitude and be a fun person to work with.
  • If there are limited computers, be careful about taking the last computer and always be ready to offer yours to a resident if all are taken.
  • Set up a plan with fellow students to share experiences such as unique surgeries or patient encounters with fellow students. Do not “steal” experiences; residents and attendings will usually find out, which can portray poorly on you.
  • Do not make your colleagues look bad.
    • During questioning sessions, only answer questions directed at you or at the entire group.
    • Don’t blame other members of the team if something has gone wrong. Even if it was a single person's mistake, let them own up to it, or simply help to find a solution.

General information

• Shelf exams are standardized tests taken at the end of each of the core clerkships.
• They assess a student's knowledge of clinically relevant information pertaining to the clerkship's specialty.
• The question format mimics the difficulty and style of questions that appear on the Step 2 CK/Level 2-CE, with some Step 1/Level 1 questions sprinkled in (e.g., anatomy) and shorter question stems on average.
• There are two types of shelf exams:
  • Standardized subject exams: created by a centralized board of examiners (NBME® for MD students; or NBOME® COMAT for DO students) and contribute towards the student's final grade
  • In-house exams: conducted by some institutions

NBME® shelf exams

NBME® shelf exams are taken by allopathic medical students at the end of each clerkship and generally include Internal Medicine, Psychiatry, Neurology, Surgery, Family Medicine, Pediatrics, and Obstetrics and Gynecology.

• Setting
  • The exams consist of 110 questions that must be completed over 2 hours and 45 minutes (∼ 90 seconds per question).
  • Can be administered either in paper-and-pencil or computer-based format
  • Usually administered by the medical school administration at a secure, on-campus location of their choosing.
• Scoring
  • The two-digit score (0–100%) on the score report corresponds to the percentage of questions on a given topic that students would be expected to answer correctly.
  • The subject examination scores are equated across test administrations and are statistically adjusted for variations in test form difficulty.

NBOME® COMAT shelf exams

COMAT exams are taken by osteopathic medical students at the end of each of the eight core clinical rotations and generally include Family Medicine, Internal Medicine, Emergency Medicine, Obstetrics and Gynecology, Osteopathic Principles and Practice, Pediatrics, Psychiatry, and Surgery.

• Setting
  • Each exam consists of 125 clinical vignette-based items that must be completed over 2 hours and 30 minutes (∼ 72 seconds per question).
  • These exams are administered at the student's medical school or at designated examination sites.
• Scoring: The scores are calculated with 100 as the mean and a standard deviation of 10 based on nationally standardized student performance data.

Tips and tricks

Fill in the gaps

• Shelf exams cover a wide range of topics, some of which may not be encountered in the clinical setting of your clerkships, especially because some clerkships may involve being assigned to a subspeciality service (e.g., Cardiology within Internal Medicine).
• So it is important to study beyond the scope of your daily clinical activities, as topics uncommon in daily practice may be overrepresented in the exam.

Approach to questions

• Clinical vignettes feature chief concern, medical histories, physical exam findings, lab values, imaging and other diagnostic findings, or a combination of these components, always in the same order and with often extraneous details. The sheer amount of information can make it overwhelming to orient your thought process at first, so get to know the order in which information is presented to make the question more digestible.
• When approaching questions, it is usually best to first read the lead-in question (last sentence) to help orient yourself for what information you should look for specifically within the stem.
  • Rarely you can answer a question without even needing to read the rest of the stem!
• In a long vignette, look for confirmatory findings in the sentence or two before the lead-in question. Doing so will sometimes allow you to make a diagnosis and/or determine the answer without having to read the rest of the vignette!
• If you must read the whole vignette, focus on highlighting only information that is unique and differentiating. Using the AMBOSS highlight feature can help train you in doing so!
• Try to determine an answer without looking at the options. As soon as you believe you know the answer, stop to see if it is among the options. If so, select and move on. At this point, do not spend time trying to reconfirm or then rule other options out, unless you have reason to believe you overlooked some important detail.
• If you do not know the answer after reading the whole stem, do not panic! Everyone will get questions wrong, so you are not alone. At this point, quickly use a process of elimination of options that can be ruled out, and make an educated guess from the remaining options. We recommend choosing the item that is most recognizable to you at that point rather than something you have rarely encountered while studying.
• Watch the clock: It is important to not spend too much time on a single question. It is better to quickly make an educated guess so you have plenty of time for questions you definitely know later on. You can always come back if you have extra time in the end.
• The more practice questions you do, the better you will get at doing questions and the more you will learn. Check out the AMBOSS Qbank for over 3,600 shelf exam practice questions!

Study schedules change drastically when students transition from the preclinical to the clinical stage of medical school.

• During the preclinical stage, unstructured time is plenty and most learning is of theoretical knowledge that takes place through lectures, books, or group activities.
• In contrast, most clerkship learning takes place through practical clinical activities, leaving students struggling to find study time. There are a number of reasons why study time is hard to come by:
  • Clerkships start early in the morning and often go late in the evening, especially for surgical rotations.
  • Many clerkships involve at least some weekend shifts.
  • Fulfilling clinical tasks may not leave much free time throughout the day for self-study.
  • The demands of clinical life and new challenges that require satisfying patients and preceptors can be exhausting. Combined with likely getting less sleep, it can be difficult to focus in the evening.
  • On top of that, your day-to-day schedule will often change as you take care of different patients and move between different facilities or clerkships.

Here are some tips to keep in mind when finding time to study:

Remember that you are human

• Keep in mind that good physical and mental health is the foundation for achieving good grades and providing the best care for your patients.
• Sacrificing sufficient sleep (e.g., < 7 hours) or skipping meals to squeeze in extra study time can actually result in diminishing returns as your mental capacity for problem-solving and social interactions may wane.
• Neglecting your other basic human needs can also negatively affect your mental capacity, so it is best to maintain a happy and healthy life as much as possible (e.g., continuing hobbies, exercising, and planning social events).

Be flexible

Since study time is both limited, inconsistent, and unpredictable, adopting a flexible study plan is usually best.

Make the most of your time

• Most clerkship days will contain some unstructured chunks of time, e.g., ranging from 10 minutes to 2 hours, during which you can study.
• These chunks of time could occur on days in which clinical activities are light, or the residents and attendings responsible for managing your day deem it appropriate that you study.
• Consider grouping your study tasks into longer ones (e.g., reading about a new condition) and shorter ones (e.g., reviewing an Anki deck), and then adjust your in-hospital studies to the schedule you have by assigning tasks accordingly.
• Do not try to simulate test-taking conditions in the clinical environment; you never know when a planned 1-hour study session is interrupted to attend to a patient.
• Try to plan smaller tasks for when interruptions are more probable.
• Be prepared: Always have study resources available; tablets/phones with apps (e.g., AMBOSS apps) are especially convenient.

Become an early bird

• Some people's circadian rhythm just happens to align better so that they have more energy and focus during the evening. Such students may struggle less with evening study during clerkships.
• For those who struggle to study in the evenings after a long day of clinical activities, though, implementing some early-morning, preclinical study sessions can be helpful.
• Waking up at 5 AM for clerkship activities seems like an impossible task at first, but it can actually become quite natural once you get the hang of it. You might even find yourself waking up that early on your days off!

Study on weekends

• Medical students are typically granted at least one day off in seven.
• Set aside the most taxing aspects of your study for the time, such as simulating a shelf exam, for the weekend.

You will have an unpredictable schedule during some of the clerkships and most likely be disrupted frequently. Remain calm and optimize your study process by filling in the available time with easily accomplishable tasks.

Adapt to patient encounters

• Researching information for clinical care situations can also coincide with studying shelf exam topics.
• Whenever possible, adapt your schedule to study topics that overlap with current patient encounters. There is no better way to quickly learn, understand, and retain information than working with it live.
• However, continue to study also topics unrelated to patients to avoid knowledge gaps on test day.
• When looking up a specific fact (e.g., guidelines for how to treat a particular condition), also briefly get an overview of the disease such as clinical features, diagnostic criteria, and prognosis.
• After reviewing medical information for patient encounters, test your knowledge on that subject with practice questions.

It is not enough to only study content related to patient encounters, as this can leave you with some substantial knowledge gaps on test day!

Study strategies for the shelf exam

• Already start studying on day 1 of the rotation to cover the broad knowledge tested on shelf exams.
• Follow the two key foundations for this exam:
  • Develop a strong knowledge base (e.g., by using the AMBOSS Library).
  • Apply your knowledge base by practicing with questions (e.g., by using the AMBOSS Qbank and personalized study recommendations in the Analysis to fill knowledge gaps)
• Create a study plan as soon as you know the schedule for your rotations, and adapt it as needed.
• Aim to finish an initial review of all topics at least 4–5 days before the shelf exam.
  • Do the practice shelf exams to test your competency.
  • Use the last days to review any weaknesses.
  • Do not study on test day! Your mind and thought process will benefit more from rest than trying to cram more last-minute facts.

Trust your study plan and be consistent. This will allow you to use your study time effectively and help you feel confident when taking the shelf exam!

AMBOSS has created study plans with recommended articles and questions for all clerkships and many subspecialties:

• Internal medicine: https://go.amboss.com/medicine ^[2]
  • Cardiology and angiology: https://go.amboss.com/cardiology-angiology ^[3]
  • Pulmonology: https://go.amboss.com/pulmonology ^[4]
  • Gastroenterology: https://go.amboss.com/gastroenterology ^[5]
  • Hematology and oncology: https://go.amboss.com/hematology-oncology ^[6]
  • Nephrology: https://go.amboss.com/nephrology ^[7]
  • Endocrinology and metabolism: https://go.amboss.com/endocrinology ^[8]
  • Rheumatology and immunology: https://go.amboss.com/rheumatology ^[9]
  • Infectious diseases: https://go.amboss.com/infectious-diseases ^[10]
  • Dermatology: https://go.amboss.com/dermatology ^[11]
• Surgery: https://go.amboss.com/surgery ^[12]
  • ENT: https://go.amboss.com/ent ^[13]
  • Urology: https://go.amboss.com/urology ^[14]
• Neurology: https://go.amboss.com/neurology ^[15]
  • Ophthalmology: https://go.amboss.com/ophthalmology ^[16]
• Psychiatry: https://go.amboss.com/psychiatry ^[17]
• OB/GYN: https://go.amboss.com/ob-gyn ^[18]
• Pediatrics: https://go.amboss.com/pediatrics ^[19]
  • Genetics: https://go.amboss.com/genetics ^[20]
• Family medicine: https://go.amboss.com/family-medicine ^[21]
• Emergency medicine: https://go.amboss.com/emergency-medicine ^[22]

AMBOSS

AMBOSS is both your clinical reference and exam study resource. It contains over 900 articles with multimedia on different medical topics and over 5000 questions to help you shine in the clinic and exceed on your shelf exam. There are also curated study plans for all clerkships and many subspecialties (see “AMBOSS study plans” above).

Interactive library

• Use to:
  • Read about the conditions of patients you encounter.
  • Quickly access the required topics before rounds (e.g., in the AMBOSS Knowledge App).
  • Prepare for questions from your attendings.
  • Build up your theoretical knowledge for the shelf exams.
• AMBOSS has numerous features to ensure the best learning experience.
  • The high-yield feature will help you focus on what is most important to know for your next exam.
  • The learning radar identifies information related to questions you got wrong. Studying this red text will fill in your knowledge gaps.
  • Supplementary interactive materials such as videos, flow charts, illustrations, table quizzes, and images with overlays (including imaging modalities, ECGs, and histopathology) help you study more in-depth and learn important clinical skills.
  • Favorite specific articles to access them even quicker.
  • With the AMBOSS Knowledge App, the interactive library is always in your pocket and available even offline.

Question bank

• Study on-the-go with the app for iOS or Android.
  • You can squeeze practice questions into your schedule anytime without using your computer.
  • The app is available offline so you can keep studying anywhere, e.g., on the bus, waiting in line, or during downtime between rounding and the next admission.
• Simulate exam conditions: Each session is customizable so you can model your exam sessions according to your study objective.
• Use the Qbank features to make the most out of your study time.
  • Enable “Key info” to spotlight the most important information in any question stem and practice your highlighting skills.
  • Find explanations written with a maximum teaching effect for each option so you can better understand why something is right or wrong.
  • Identify your strengths and weaknesses with a detailed performance analysis of each Qbank session.

Apps

• Flashcards
  • Anki (with AMBOSS Anki add-on):
    • AMBOSS Anki add-on connects any Anki deck to the AMBOSS library
    • You can find the instructions on how to download, install, and use the add-on on the AMBOSS website ^[23]
    • You can create your own decks or search for and download the existing ones. ^[24][25] AMBOSS will be integrated into any deck.
  • Quizlet: Use the on-site search for finding the decks.
• Pharmacology:
  • Micromedex® ^[26]
  • CredibleMeds® ^[27]
  • Drugs.com ^[28]
  • Epocrates®
• Calculators
  • Calculate by QxMD ^[29]
  • ASCVD (Atherosclerotic cardiovascular disease) Calculator ^[30]
  • MDCalc ^[31]
• Clinical case discussions
  • Clinical Problem Solvers ^[32]
  • Figure 1 ^[33]
  • MedShr ^[34]

Professional organizations

• American College of Physicians: Membership includes access to Annals of Internal Medicine and DynaMed. ^[35][36]
• American Academy of Family Physicians (AAFP): Membership includes access to the online journal American Family Physician. ^[37]
• American College of Surgeons (ACS): Membership includes access to the Journal of the American College of Surgeons and other publications including the Medical Student News. ^[38]
• American Academy of Pediatrics (AAP): Membership includes access to PediaLink® for Medical Students. ^[39]
• American Psychiatric Association (APA): Membership includes a subscription to the American Journal of Psychiatry and Psychiatric News. ^[40]
• American Academy of Neurology (AAN): Membership includes registration to the AAN Annual Meeting and several publications. ^[41]
• American College of Obstetricians and Gynecologists (ACOG) ^[42]

Guidelines

• USPSTF (United States Preventive Services Task Force) guidelines for screening measures: AHRQ ePSS provide guidelines for screening and prevention of different communicable and noncommunicable diseases ^[43]
• ACP (American College of Physicians) Guidelines ^[44]
• CDC (Centers for Disease Control and Preventions) recommendations and vaccine schedule: You will find keeping up with the vaccination guidelines particularly important for your Family Medicine, Pediatrics, and Ob&Gyn clerkships. ^[45]
• AAFP (American Academy of Family Physicians) Guidelines: ^[37]
  • Guidelines from the AAFP can be used as a quick reference, especially during your Family Medicine and Pediatrics clerkships.
  • However, aim to use the specialty society guidelines if such are available.
• Specific specialty society websites (e.g., aan.com for Neurology)
• See articles of specific clerkships for more associated guidelines.

Books and readings

• Case Files® series: for those who like to learn from cases
• Cochrane: a large database of meta-analyses performed by the members of Cochrane Collaboration ^[46]
• NEJM Resident 360: a discussion and reference platform for students and residents that provides tips for preparation to different rotations as well as career advice ^[47]
• NEJM Interactive Cases: a library of more than 60 illustrated clinical cases with teaching slides ^[48]