Overview

Yes, this year is the toughest.  You will be frustrated and confused with the new settings you are introduced to.  As soon as you start to understand how things work or what faculty and residents want, you switch rotations or work with new people.  Just hang in there and try to ask as many questions as possible in order to understand what you should do to succeed.  The quicker you find out how things work, the quicker you can work more effectively and look good to your evaluators.  The added stress of having departmental or shelf exams makes the lack of time outside of clinical responsibilities that much worse.  Come early, stay late, act interested, and do everything you can to be helpful.  This year will end eventually and when you think about it afterwards, you realize that you absorbed a large about of clinical information without noticing it.  Since EM encompasses many specialties, you will be able to use what you learn in various rotations in your career.

 

Keys to your success

1. You will have less time to do the extracurricular activities that a 1^st or 2^nd year student will.  Do what you can, work hard on your rotations, and get as much sleep as you can.

2. Improve your H&P skills in Family Medicine, Internal Medicine, and Pediatrics.  Maybe you will get some procedures in Meds, Peds, or Surgery (lines, LPs, suturing, trauma call).  Deliver some babies in Ob/Gyn, work on your pelvic exams, and get comfortable with ultrasounds.  Psychiatry will prepare you for many of those ED patients.

 

My experiences

I kept working hard to get good evaluations and good exam scores.  Sometimes it is tough when residents or faculty hold you in the hospital despite a lack of clinical work to be done.  Carry pocket books and guides so that you can get some studying done when you are stuck doing nothing.  Things get easier once you realize where the vitals are recorded, how to get some supplies, and where the patients are located!  Therefore, when you don’t know something, ask and remember it for next time so that you become more efficient.  Below are some beneficial experiences I had during my 3^rd year.  The rotations are in the order I had them. 

 

-I began 3^rd year with Family Medicine.  This was pretty much a preceptorship at a private practice office.  I took the time to learn how to draw blood since UTMB did not have such classes for med students for my year.  I gave shots and became more comfortable with seeing patients.  The first few times I asked, I had to watch various people draw blood and give shots, but then after some persistence, they finally give in.

-For Pediatrics, I lost an LP to an R3 and one to an Acting Intern, but it was still early in the year.  I got to know some of the nurses and they let me do some basic things like put in a Dobbhoff tube, draw blood, and attempt IVs.  The key is to have a good rapport with everyone and do not be afraid to ask for the opportunity.  On my very first day in pediatrics (my first inpatient rotation), I was assigned to the PICU.  A code was called on a patient.  When she was brought down to the unit, the attending asked me to help push fluids through her IV access.  This was also the first Foley I placed. 

-Internal Medicine had 2 rotations.  I started on a general medicine team.  This where I saw my first central line placements.  I got to help with some, but I was still working on putting in IVs.  Once again, nurses will be reluctant to let you stick their patients sometimes, but after getting to know them and after reiterating my wish to learn, they would call me over when there was a “good” patient to attempt an IV on.  I saw my first adult code during this rotation.  Prior to the rotation, we were given the opportunity to request our subspecialty rotation.  I asked for cardiology and was fortunate enough to be assigned to it.  I saw mainly telemetry patients and became decent at looking at ECGs (but I still have a ways to go as far as confidently interpreting all of them).  I saw some critical patients in the CCU that had to be intubated or didn’t do well after cardiac cath.  I learned a lot from my faculty who taught us how to read some TTEs.  That proved helpful for understanding ultrasounds in the future.  I feel that I was much better with abnormal heart sounds after that cardiology rotation.  The moral of the story is that if you can request the subspecialty rotations at you school, try to choose something that will help you with EM.

-Surgery was tough.  I got to do some suturing, learn how to tie (one and two handed), and put in more Foleys.  Trauma call was interesting when the critical patients came in.  Getting used to going over the primary (ABCs or ABCDE) and secondary surveys was beneficial.

-Ophthalmology Research Elective – I learned to use the slit lamp and saw a few eye surgeries.  I had this elective during the Christmas break time so I was able to take some time looking into the EM field.

-MAC (Multidisciplinary Ambulatory Course) or my outpatient experience was a nice rotation in Victoria, TX, where I continued to work on my H&Ps.  There were a few shots and blood draws here and there.  I probably saw enough ears and throats during my days at the pedi clinic to know erythema when I see it.  I began to try and be confident with stating my assessments and plans with my attendings (pediatrician, internist, and family physician).  On my free evenings and free days, I spent time in the urgent care clinic and ED.  I was able to work with an EM trained physician and ask him questions.  I also knew the infectious disease physician who came to see an HIV patient in the ED.  That was my first LP (after asking for the procedure, of course).  I was not successful, but it was good to feel more comfortable with the setup of the LP tray and have some experience with poking a patient with a spinal needle.

-Psychiatry was another nice rotation.  I got better at the Mini-Mental Status Exam.

-Ob/Gyn­ was where I did some suturing, plenty of pelvics, saw some pelvic ultrasounds, watched plenty of deliveries, and delivered two babies.  Those two deliveries were with midwives at the Birthing Center.  Every time there was a delivery in L&D during the days or on call, it would be a C-section.  I guess that is a result of being at a county hospital.  The key to getting to at least deliver a couple of babies was that during down time on L&D call, I asked the resident if I could go hunting for deliveries at the Birthing Center.  I spoke with the midwives who said that I needed to introduce myself, spend some times with the families, and follow the mother’s progress. 

 

Some may argue with really needing to draw blood or do IVs as a med student.  Although I will be primarily expected to put in central lines as a resident, I was impressed that Dr. Kuppermann (Pediatric EP at UC Davis) was able to quickly place an IV in a small child who was needing resuscitation while the only nurse available was busy doing something else for the patient.  Usually the nurses will be much better than the doctors at IVs and if they can’t get it, the physicians then attempt central lines or worse, intraosseous lines and saphenous cutdowns.  Still, I feel it was good to be aggressive and learn the IV skills so that I was comfortable with performing procedures as a student.  I wish I had more central line experience, but I am sure I will get plenty as a resident.  Another justification for learning how to draw blood and start IVs is that if all the nurses and ancillary staff are backed up, you have the confidence to try and do it yourself so that you can get things moving faster (but make sure you use the right blood tubes).

 

When I realized that EM was for me, I started researching the field on the web.  I decided after my surgery rotation that I liked procedures and critical patients, but surgery did not match my goals of having more time with family and better flexibility with my schedule.  I thought about Ophthalmology briefly, but decided it was too focused of a field.  I read Iserson’s “Getting into a Residency” and another book entitled “Choosing a Medical Specialty.”  I finally realized that EM was perfect for me.  Over December, I looked through the SAEM residency catalogue and looked at each program’s website.  I read the advice on away rotations and other student pearls (see links page).  I joined ACEP/EMRA, SAEM, and AAEM and read their newsletters/journals.

 

Setting up away rotations (aka: visiting rotations, audition rotations, externships)

At the end of MAC in March, I started looking into away rotations.  I was waiting for my class meeting to determine when I would do away rotations.  I did not realize that we could block off months we planned to be away.  Had I known this, I would have started working on solidifying away rotation dates, but it was still early anyway.  I looked on the various EM residency websites (via SAEM) and read about their away rotations.  SAEM also has an away rotation page, but I just went through programs’ websites to look for “student rotations/externships.”  As you select away rotations, keep the following in mind…

 

1. Openings? - Some fill up fast, so contact them early.
2. Guaranteed spot? - Some will pencil you in so that you can rely on having a rotation at that time in your 4^th year schedule.  (That’s why I did my EM rotations at UTSW, U of Louisville, and UC-Davis and did my EM Ultrasound Elective at UC-Irvine.  Others will let you know later after their home students have sign up and then there will be less alternatives to choose from by that time if you do not get a spot.  You can choose to apply to several away rotations and cancel the alternatives, but some may keep a deposit or send your school an evil letter.  Check their policies before doing this.  I emailed or called to confirm my position before making permanent arrangements.  (Living in the Central Time Zone is nice.  I was able to call the EST places in the morning before my rotation responsibilities started and the PST programs in the afternoon after my day at the hospital.)
3. Common requirements – Most schools require your school’s official away rotation forms, proof of malpractice insurance, immunizations, etc.  Give yourself plenty of time for the Red Tape to slow down the process of getting that magic sheet of paper that you just want to fax to the away rotation of your choice before the rest of America takes your spot!  You may have to clear things up like a hold or missed immunization and schedule to get that done.  Then it takes time for the computers or system to file the changes and then… you get the picture.  One of my friends wanted to rotate in New York, but he said they required higher malpractice coverage than what our medical school provided so he could not rotate there. 
4. Requirement details - Some of the requirements may include a deposit (non-refundable), fee ($50 to the UC Regents), a letter of recommendation (an Arizona program wanted a faculty member while some others just needed a generic letter from your dean’s office saying that you are a matriculating student).  Other places sometimes ask for proof of ACLS training, health insurance, etc.
5. Flexibile? – Some schools insist that you go by their 4 week schedule.  If this doesn’t match up with your school’s blocks, then it could cause you to use two blocks to fit in that one away rotation.  When I initially looked at UTSW’s website, it stated that away students had to rotate according to UTSW’s schedule.  They were a week off from my schedule so I initially did not sign up for an externship there.  Later, I emailed the student coordinator and she said that they were flexible so I was glad I could apply.
6. Housing – I stayed with my college buddy in Dallas, my wife’s cousin in Louisville, and my (long-lost) cousin (in-law) in LA County.  That saves lots of money.  Some places have student housing that you can pay for.  I know lots of people from UTMB that stayed at affordable “bed and breakfast” establishments in New Orleans while rotating at Charity.  Several places will provide you with a list of people renting a room in their house for the month.  (My friends rented for about $300 in Albuquerque, I rented for $350 in Sacramento from a nurse who lived a few blocks from the hospital, and UC-Irvine’s list had people asking for $900 for a month, but fortunately I found that (long-lost) cousin (in-law) of mine.  I have noticed that EKL in Baton Rouge offer free housing on their website.  While interviewing at Christiana Care in Delaware, away students stayed in the Hilton Garden Inn nearby and the program paid for it!  I tried to get student housing at UC-Irvine’s undergrad campus.  Remember that some undergraduate campuses are not exactly next to the medical campuses/hospitals.
7. Timing – An earlier externship means more interns that may take your procedures and a less organized rotation that has not worked out the kinks for the year.  My rotation at Dallas was perfect with the first week or so with all the residents at the end of their year.  I did lots of procedures and it did go down somewhat when their year switched and new interns were starting.  Still, they expect you to know less early in the year.  Of course, the earlier you rotate, the earlier you can get a standard letter of recommendation (SLOR).  This means you may or may not start getting interviews earlier.  If you rotate later, you may get to interview while you are there.  While rotating at UC-Irvine, I was able to do a couple of interviews at other programs in Los Angeles.  Many with spouses who are teaches went during the first fourth year rotation so that their spouse could come with them while they were still on summer vacation.
8. Residency – If you want to go to a certain program or area, definitely try to rotate there and do the best you can.  A few programs are notorious for taking very few students that do not rotate there so unless you walk on water, plan on getting that away rotation set up if you really want to go there.
9. Prestige – So you want to eventually be at a big time program?  Well, it is sometimes debatable what the “top” programs are, but you can look at books like Tintinalli, Rosen’s, Hardwood-Nuss, etc. and look at the main authors and contributors to see where they are from.  Look at Annals of Emergency Medicine and Academic Emergency Medicine for chief editors and those that publish often.  Ask your advisor or other EM faculty for their opinions.  Look through their website and see where their faculty and residents are from.  Your dean’s or student affairs office should have a list of unfilled programs from the previous years.  Sometimes, a new program can be a great opportunity, but remember that if they are in their first year of existence, you will have no EM third year residents to teach you when you rotate that next year.  Usually, the more established programs will have the kinks worked out and more respect from the other departments in the hospital.  Some say that it is better if a program is an EM “department” instead of a “division” but that is not a hard and fast rule.  Some places will have more control or responsibilities with traumas and airways.  Many of these details are things you will consider when applying and ranking programs next year as an MS4.

 

Be sure to check out the links page for other resources (EMRA, SAEM, etc.) to learn more about this topic.

 

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Last updated on 3/16/04

 

Questions, comments, suggestions?  Feel free to contact me at [email protected] (I will reply as soon as possible.)

 

(EM=Emergency Medicine, ED=Emergency Department, EP=Emergency Physician)