A Whirlwind Guide to the Third Year

Introduction

All that studying you did first and second year will finally be put to use during the third year. Despite occasional moments of sheer frustration, the excitement of patient care and having a taste of life after medical school can’t be beat! But don’t be fooled. Third year also has its pitfalls. Never before and never again will you have such a rigorous schedule during which you will know all details of your patients’ care and still know that you have to study for an exam that will likely not test you on what you spent all day trying to learn. You will also be glad when this year is behind you.

There is no one best approach to third year, but most will agree that enthusiasm and commitment to being a team player will take you far during this long year. Every team will appreciate a student who is eager to learn and to be a team player. Students who try to make themselves look good at the expense of others quickly become apparent and will likely not earn the trust of the team. The team will also expect you to, on occasion, do what seems like pointless work. This work is called scut. You will have to determine for yourself where to draw the line between doing scut and not, but you’ll find that doing scut often does have some value in your education; the time you save your team will (or at least should) buy some time for teaching and learning.

Common sense will soon tell you that as a third year you really don’t know much that matters to the day-to-day inner workings of patient care. In spite of this, you will have the unique opportunity to know everything about your patients. You will carry a manageable number of patients (unlike your intern for whom there is no mercy!) and you have the luxury of having just completed CPP. Treating the nurses and ancillary staff with kindness will save you when your team asks you to get "that stretchy tape" that everyone on the team seems to know except you. Your role will be like that of a sponge - to soak in all of the information and good (and bad) role modeling that you will see around you. Before you know it, you will finally develop your own style during third year. You’ll realize that you still have a long way to go, but the overwhelming sense of accomplishment, knowing that you’ve already come a long way, can’t be beat!

Comfortable shoes will come to symbolize your having to be several places at once in a given day, as will the multiple hats you will wear throughout the year as you rotate through virtually every aspect of medicine. One minute you will be holding a retractor that is digging into your hand that you know you can’t move. In another you’ll be standing outside your patients’ room as your attending describes every intricacy of the urine chloride level as a valuable diagnostic tool. Next you’ll be running in the rain trying to catch a flight to Denver for an organ harvest at 2am in the morning, or more likely you’ll be running to catch up with your team as "DR CART! DR CART! D-504!" blares overhead. Nevertheless, one of the challenges and beauties of this year is that you will be everywhere. You will know the hospital in general better than any intern. Someday your team may have to get from the children’s hospital to the OB/GYN library and only you will know the shortcut!

Being everywhere has its drawbacks. Once you have finally reached some sense of equilibrium where you are, your rotation is over and you are whisked away to another service to find that you are back to square one. But don’t fear. The "stupid time" during which you feel utterly lost and confused at the beginning of each rotation shortens as you go, and by the end of the year you’ll have mastered how to get around and will begin to figure out which "rotation" you want to make into your career. Through all of the rotations and rounds, you will find that this will likely be one of the most challenging times of your life. You will be asked to do what seems to be superhuman and you may wonder if you will ever know enough. Balance will, more than ever before, be the key to your success. Balance between reading about what you think is interesting and what you need to know. Balance between sleep and study. Balance between your professional and your personal lives. The tools you develop to balance these priorities this year will last you a lifetime.

The Third Year Curriculum

With the input of your classmates as representatives on the various school curriculum development committees, the Third Year Curriculum has evolved to balance your needs with the demands of a changing medical world.

The year is divided into six clerkships: three months each of surgery and internal medicine, one month of family medicine, two months of pediatrics, and six weeks each of OB/GYN and psychiatry. Each clerkship is subdivided into various rotations during which you will see different aspects of that field. Between the clerkships you will have vacation varying in length from a weekend to ten days depending on the length of your rotation and the time of year. Interspersed throughout will be a combination of inpatient and outpatient care during which your day may vary from 9am-5pm to 5am-9pm.

Clerkship Lottery

During your second year you will be asked to rank in order of priority the twenty-four possible combinations of clerkship orders. The computer assigns you a random number which is then ranked and rotations are assigned, based on that random rank. Believe it or not, the system actually works and most people will discover that there is really not that much difference between their first and fourth choices. In the small chance that things didn’t work out or circumstances change, you will have the opportunity to swap rotations once the first lottery results are posted.

Much will be made of the order in which you do your rotations. You will have ample opportunity to consider this decision as the second year draws to a close. The bottom line is that you will have to determine for yourself which priorities are more important to you at what time and which clerkship order will likely best meet those priorities. Keep in mind that there is an outpatient component to every clerkship so you will have flexibility throughout the year to juggle weddings and other hallmark events. In spite of this, the larger concern of how best to prepare for fourth year and indeed your career with your clerkship order will undoubtedly come into question.

While no one can give you definitive answers, it helps to consider some important questions. How do you learn best? Are you at your best after you have had time to "build up" or do you burn out and need to hit the ground running? Are there any important events like weddings that you will need to plan around? What experiences do you think will be most important to have by the end of third year when you will need to plan your fourth year? And note, there is no universal rule about when to do what "you think you want to do" because a) that may change, and b) you might find that there are benefits to doing that field first when you’re fresh or last when you’re seasoned. Bottom line: don’t stress! It will work out!

The Medicine Clerkship

Directors of Medical Student Education, Medicine

Adam Corfu, M.D., Patricia Kurtz, M.D., and

Scott Stem, M.D.

Medicine Student Program Coordinator

Debra Milton

Office of Medical Student Programs, Medicine

Billings Hospital, Room A-615

702-0351

Although it is one of the most challenging times of the year, most will agree that your three month medicine rotation is also one where opportunities to learn will abound. During your inpatient months, you will be asked to follow two to four patients, meaning that you will assist the team during their admission, gather information pertinent to their day-to-day hospital course and begin to formulate your thoughts on their day-to-day management. Days generally last 10 to 12 hours and you will be on call every fourth night (q4) during your inpatient months, one of which is spent in general internal medicine ("gens") and the other in a medicine specialty (cardiology, heme-onc, or GI/private). During the outpatient month you will work approximately 8:30-5, five days a week, with no call. This outpatient month may be done at U of C or at various sites throughout the city, each with its different patient population and different attending faculty.

Inpatient Month

On top of your patient care and team responsibilities, your days are interspersed with various conferences and meetings. At your faculty preceptor group, you will have the opportunity to discuss concerns that arise on the floors with your patients as well as others that you or your preceptor introduce at each meeting. Although you are not fed lunch as are the interns in medicine or the interns and students on other rotations, you will also be asked to attend lunch conferences and grand rounds. Much is made of rounds in internal medicine. An opportunity to hear an expert deliver a presentation, the weekly grand rounds is a chance for you to finally sit down, relax, and try to learn a thing or two from someone sitting far away in the dark...

A typical inpatient day might be as follows:

7am Preround. Gather information on your patients and prepare for workrounds.

7:30-9 Workrounds. Same as above but with

your residents and interns.

9-10am Floor work. Gather morning labs,

schedule procedures, write notes.

10am-?? Attending Rounds. Present your

patients, discuss other related topics,

discuss other unrelated topics.

Your time to learn!

Lunch Conference

1-4pm More floor work

4-5pm Lecture

5-? Finish up floor work, usually home by 7pm.

Outpatient Month

The month of outpatient medicine can be a great experience regardless of what you think you want to do. After taking a focused history and performing a pertinent physical exam you will present your thoughts to your attending and work together to formulate a plan for your patients. During the month of outpatient work, you will also be required to meet with the other outpatient students and present formal cases as well as talks on topics related to the presentations. Typically your days are shorter than on inpatient services and don’t include weekends, so you will have time at night and on weekends to catch up on sleep, reading or having a social life!

Clinical Evaluation

Students are evaluated in several areas, including the quality of written and oral presentations, the ability to formulate a case,, general fund of knowledge, the ability to interact with patients and colleagues, reliability in caring for patients, and humanistic qualities. Emphasize your oral presentations. These 4 - 6 minute spiels may be the best and only chance for your attending to see you in action. Make sure you have reviewed your presentation at least once with a resident before you formally present on attending rounds.

For all students, the course directors solicit opinions on the student’s clinical performance from physicians with whom the student works, including the preceptor and house staff. Although all physicians are encouraged to return written evaluations, usually with a grade (honors, high pass, pass, low pass, fail), only attending physicians and the preceptor are required to do so. The course directors encourage each attending to meet personally with each student in order to provide feedback throughout the rotation. In reality, this may not always happen and you might find that stepping forward to ask your attending about your progress might do the trick. Although it is easier said than done, don’t let the rotation pass without knowing from your attending what he or she expects. How you perceive your day-to-day performance may differ greatly from theirs, and for the purposes of your grade, its their perception that counts. While your residents and interns may have input, depending on your attending, your clinical grade will come down to how your attending feels you have progressed throughout the month.

Examinations

There is a comprehensive two-and-one-half hour multiple choice written examination (NBME Subject Exam) at the end of the clerkship. There is no oral exam in Medicine.

Final Evaluation

A composite clinical grade is calculated from the individual grades received from your preceptor and your attendings on each rotation with grades being averaged for a particular rotation if more than one physician was on service. An overall clerkship grade is determined by considering each student’s composite clinical grade, presentation grade, and final exam grade. The relative weights of each component of your performance is then applied to each grade and a final grade is calculated. You and the Dean of Students Office will receive a summary of the comments made by the student’s attending physicians as well as the overall clerkship grade and exam grade.

Informal Guide to Medicine

Due to its combination of patient care responsibility, long hours, emphasis on write-ups and presentations, call every fourth night, and a paucity of days off, medicine has traditionally been one of the toughest rotations of the third year. It can also be one of the best experiences of the year providing a chance to pick up some practical medical knowledge.

For survival and sanity on the medicine rotations, it pays to be organized and efficient. Your attention to detail balanced by your grasp of the big picture will determine your success. Make time while on call to read up on your patients and to prepare your presentations for the attending. Consult your resident for tips and suggestions on your presentations. As you read through Harrison’s on your patients and as you learn from your interns and residents about your patients, you may come across a particular issue that might warrant a literature search. Whether you distribute copies of the article or simply mention that you read about it, your involvement in the care of your patient will be evident and more importantly you will truly begin to learn about the science of medicine. From time to time, you will be asked to informally present a topic to your team. Seeing this not simply as work to keep you busy, but rather as a chance to develop your fund of knowledge will also get you far!

Preparing for the daily care for patient care may not always overlap with the preparation you do for the test. In fact, through all of the excitement of patient care, it can be easy to neglect until it is too late to prepare for the exam. This is one of the easiest ways to ensure that your excellent clinical grade will be negated by a sub par exam grade. The reality is that you are still a medical student and that the bottom line is not decided by just your clinical performance. You’ll find that a large majority of your performance is made or broken by your written exam, so DO THOSE QUESTIONS!

Now for some practical advice. Be sure that you have enough "work clothes" so that you are not doing laundry every week. Scrubs unlike on other clerkships, should not be your staple on medicine. In fact, only on call should you wear scrubs as even on post call days there is a push to wear professional attire. Most importantly, that pair of comfortable shoes combined with "easy to prepare" food at easy reach will ensure that your focus is one the task at hand.

The Pediatrics Clerkship

Director of Medical Student Education, Pediatrics

Joel Schwab, M.D.

Pediatrics Student Program Coordinator

Evelyn Simpson, for MS IV

Marie Shelton, for MS III

Office of Medical Student Programs, Pediatrics

University of Chicago Children’s Hospital,

Room C-376, 705-4718

The Pediatrics junior clerkship is divided into an inpatient month and an outpatient month. While it might seem that pediatrics is simply internal medicine for little adults, you’ll quickly find that this is not the case. While this rotation is relatively busy, most students, whether or not they are interested in pediatrics as a career, find that the rotation is enjoyable and laid back.

Inpatient Peds

The inpatient month can be done at the University of Chicago Children’s Hospital (UCCH) or La Rabida Children’s Hospital and Research Center ("LaRa"). The outpatient month is held at one of a number of on- and offsite pediatrics clinics run by the UCCH. Throughout the two months, you will also be assigned to a pediatric specialty clinic which meets for one half day a week, as well as to a preceptor group similar in style to that of medicine.

While on the pediatric inpatient service, you will participate as a member of the ward team and assume a prominent role in the management of the patients you admit. Considerable effort is expected on your part to get the most out of this rotation. You will take call q4 but you will generally have at least a weekend day off per week with the exception of one weekend when you take call on Saturday.

A typical inpatient day might be as follows:

7am Preround. Gather information on your

patients and prepare for workrounds.

7:30-9 Team Rounds. Same as above but

with your attending, residents and

interns.

9-10:30 Morning Report.

11am Sit down discussions about various

peds topics

Lunch Intern Conference

1-4pm More floor work / preceptor group

4-5pm Lecture

5-? Finish up floor work, usually home by 6pm.

Outpatient and Specialty Rotations

During the outpatient month of the clerkship, you are exposed to general pediatric clinics and the newborn nursery and you will be able to build a close relationship with your attending. In clinic, you see the walk-in patients first. After taking their history, doing a physical, and formulating an assessment and plan, you present your thoughts to the attending who then sees the patient with you. You’ll often have days where you see almost twenty patients, so it can seem very busy, but by day’s end you won’t believe how much you’ve learned. Typical days are from 8:00 am to 5:30pm, with weekends off!

You will also be assigned to specialty clinics one morning or afternoon each week throughout the two month clerkship. The clinics range from diabetes to chronic care. These clinics allow you to learn in more detail about pediatric sub-specialties with one-on-one attending contact.

Clinical Evaluation

A student’s clinical performance in Pediatrics is evaluated by the residents and faculty at the inpatient and outpatient training sites where the student works. They are asked to evaluate the student in several areas, including the student’s general fund of knowledge, problem-solving ability, written notes, enthusiasm, skill in working with pediatric patients, families, and colleagues, and humanistic qualities. Written evaluations are usually submitted to the departmental Office of Student Programs, and a composite clinical grade is determined from these evaluations.

Examinations

There is a comprehensive, two-and-one-half hour written examination which is supplied by the National Board of Medical Examiners. The exam is administered at UCCH. There is no oral examination for pediatrics.

Final Evaluation

Each student’s clinical and examination performance is discussed and a final grade is determined by the Pediatrics faculty at a joint meeting at the end of the quarter. The composite clinical grade accounts for 70% of the final grade, and the written for 30%. The final grade is designated using the following scale: Honors, High Pass, Pass, Low Pass and Fail. A summary paragraph describing your clinical and exam performance as well as your final grade are sent to the Dean of Students’ Office and to you. As with other clerkships, the grade that appears on the student’s permanent transcript is simply P or F.

Informal Guide to Pediatrics

The atmosphere on the pediatrics rotationis unlike no other during your third year. In general, residents and attendings are much more laid back, simply because their patient population requires it! Generally, you will also have somewhat more time to read. These factors all combine to make it an enjoyable rotation, assuming you can put up with the constant crying and wailing that is like background music for most peds wards. It is also a rotation where it is advisable to carry around small toys to distract the kids while you are trying to examine them. Be sure to have access to an otoscope as well as tongue blades and an immunization schedule. In general, you’ll have to wear white coats on the inpatient service, but many outpatient services do not require white coats and the nursery forbids it, so guys you might have to iron your shirts instead of hiding them beneath your coat on this rotation. The subject exam at the end of the pediatrics rotation is often seen as the most difficult, so be prepared to know those details!

The Obstetrics & Gynecology

Clerkship

Director of Medical Student Education, OB/GYN

Sandra Valaitis, M.D.

OB/GYN Student Program Coordinator

Johnna Bullock

Office of Medical Student Programs, Ob/Gyn

Chicago Lying-In, Room L-251

702-6726

The Obstetrics/Gynecology junior clerkship is conducted at Chicago Lying-In Hospital (CLI), located in the University Medical Center. Students serve three services: (1) Labor and Delivery, (2) Obstetrics Service, and (3) General Gynecology or Gyn/Endocrinology and Gyn/Oncology. On Labor and Delivery, the student functions as a member of the Birth Room team, participating in approximately one week each of 12 hour daytime and nighttime shifts. On the Obstetrics service, the student attends the outpatient clinic at CLI where antepartum and postpartum patients are seen. During the gynecology rotation, you will either be on the general gynecology service where you will attend outpatient clinics and help in the operating room for the gynecological cases. If you are assigned to the Gyn/Onc & Gyn/Endo services you spend your time going to clinic and in the OR. The Gyn/Onc service is generally known to be one of the most rigorous of the year; you will typically begin work rounds at 5:45am so you preround before that. On the other hand Gyn/Endo tends to be very light where you will find yourself starting your day with clinic at 8:30 or 9am.

Another aspect of the clerkship are weekly chairperson’s rounds and weekly obstetric chief’s rounds where you will present at one of each. You will also meet in small groups of two or three with a faculty preceptor where you can review topics in the Student Guide to Obstetrics and Gynecology (which contains a course outline and the oral exam topics) or topics that arise in the course of patient care.

A typical inpatient day might be as follows:

6am Preround. Gather information on your

patients and prepare for workrounds.

6:30-8 Work Rounds. Same as above but

with your, residents and interns.

8-9 Morning Conference.

10am-5pm Scut with attending rounds at various

times for about an hour sometime

during the day.

Clinical Evaluation

Your clinical performance is evaluated and graded by the residents and faculty at Chicago Lying-In, MacNeal and Weiss who work with you on each rotation. Written evaluations are usually submitted to the departmental Office of Student Programs, and a composite clinical grade is determined from these evaluations and from the combined input of the faculty and housestaff.

Examinations

There is a comprehensive multiple-choice two-and-one-half hour CNBME subject exam and an oral exam at the end of the rotation. The half-hour oral exam is conducted by two faculty members and consists of patient management questions using a case format. The oral exam is graded as Honors, High Pass, Pass, Low Pass, or Fail.

Final Evaluation

Each student’s performance is discussed and a final grade determined by the Obstetrics and Gynecology faculty. The composite clinical grade accounts for 50% of the final grade, the written exam for 33%, and the oral exam for the remaining 17%. The final grade is designated using the following scale: Honors, High Pass, Pass, Low Pass, and Fail. If a Low Pass is given, a recommendation for remedial work in the senior year is usually made, and this work counts as a senior "elective." A summary paragraph describing the student’s clinical performance, as well as his/her final grade and grades on the written and oral exams, is sent to you and to the Dean of Students’ Office

Informal Guide to OB/GYN

You will see and do amazing things during this rotation. It’s a time of palpating, prying, pulling, and pushing. You will also find that this can be one of the most trying clerkships of the year, simply because of the massive variety of clinical problems you’ll encounter and the collective attitude that develops amongst your colleagues when everyone is overworked. Tempers can be short, both yours and those of your residents, but be patient and try not to take things personally. But be sure to stand up for yourself if things get out of hand. Remember that your responsibility is to accomplish work for the team and to yourself to learn this important field of medicine. If things are skewed and you aren’t learning while working, speak up. The clerkship director is very understanding and has a sincere interest in making things worthwhile for you. On the bright side, the subject exam at the end of the rotation tends to be the most straightforward.

The Psychiatry Clerkship

Director of Medical Student Education, Psychiatry

Morton M. Silverman, M.D. & Alan Sanders, M.D.

Psychiatry Student Program Coordinator

Pat Lofton

Office of Medical Student Programs, Psychiatry

Billings Hospital, Room B-330. 702-0529

The Psychiatry clerkship is now a six week rotation with weekends off and call about once per week. There are three different sites for the clerkship: University of Chicago, MacNeal Hospital at 3231 S. Euclid in Berwyn, and Tinley Park Mental Health Center in Tinley Park. The Office of Education will ask you for your preferences before the rotation and will attempt to honor them. Students at all sites have experiences in inpatient, outpatient, and emergency psychiatry. At U of C, students are also assigned to a consultation service, working with a resident and attending who see patients on the medical, surgical, and OB/GYN services when psychiatric issues enter into their care. The consultation service is interesting and valuable; it focuses on the types of psychiatric problems non-psychiatric physicians face in their clinical work. Students also hone interviewing skills, performance of the mental status examination, identification and characterization of psychiatric signs and symptoms, and the management of strong feelings which manifest in the medical interview.

Many students experience some anxiety at the prospect of working with patients with psychiatric illness. Psychiatric illnesses are very common; some students will have had experiences with psychiatrically ill friends and relatives, or suffered those illnesses themselves. If memories of such experiences persist such that they may make the rotation difficult, you are encouraged to discuss your concerns with Dr. Sanders. He can help with issues ranging from psychiatric referrals for loved ones to clerkship assignments. He is available before, during, and after the clerkship by appointment.

All students attend a common core lecture series at U of C; all take the same exam. The required texts are available in the university book store, other materials are distributed during the clerkship. Grades are based approximately two-thirds on clinical performance and one-third on the results of the exam. Each member of the housestaff and attending staff who interacts with the student completes a written evaluation of the student. Dr. Sanders synthesizes these evaluations into a summary narrative evaluation at the end of the rotation. A copy of this document is delivered to each student’s mailbox and the Dean of Students’ Office with the final clerkship grade.

Examinations and Evaluation

A student’s clinical performance is evaluated by attending physicians and housestaff. They are asked to evaluate the student in several areas, including the student’s diligence, knowledge base, skill in working with patients and colleagues, and enthusiasm. There is an NBME multiple-choice subject exam at the end of the quarter which is administered at U of C. There is no oral exam. The final clerkship grade is a composite of the written exam and clinical evaluations.

Informal Guide to the Psychiatry

This rotation is often seen as a step above vacation with the main difference being that you have to show up. Not only will this attitude undermine a critical component of your education, but you can easily fail if you do nothing, so don’t write this rotation off! Even if you think you absolutely hate it, you at least have the benefit of examining many patients who have few medical problems. In fact, you will most likely be the only person examining them closely, so take the job seriously. Regardless of what field you decide, "psychopathology is everywhere" so listen up during this rotation! The exam is pretty straight-forward but you need to know the diagnostic criteria reasonably well to differentiate between similar but clearly different patient presentations and diagnoses.

The Family Medicine

Clerkship

Directors of Med Student Education

Wylie McNabb, EdD, and Robert Avina, MD

Family Medicine Student Program Coordinator

Carol Logan, 702-3989

The month-long Family Medicine clerkship is conducted on the MacNeal campus in Berwyn, a nearby west suburb, approximately 25 minutes away by car. It is an outpatient experience in which students will spend two weeks at the MacNeal Family Medicine clinic and two weeks in the office of a Family Physician in the MacNeal community. Students work in a clinical setting four and a half days a week. Wednesday afternoons, students gather at MacNeal for didactic sessions, student presentations, and hands-on skills workshops. Emphasis is placed on outpatient topics that include: prevention and health maintenance, nutrition, substance abuse, sports medicine, and common ambulatory medical and psychosocial problems. Other experiences offered through this rotation include the MacNeal Dependency Treatment Program (MDTC), the Housecalls Program, Berwyn-Cicero Council on Aging (BCCOA, but pronounced "BOCA"), Emergency Medicine and Sports Medicine.

Clinical Evaluation

Students are evaluated by attending physicians (and residents, if applicable) with whom they work in the two clinical settings. Areas of evaluation include clinical skills (history taking, physical examination, diagnostic testing, medical management, patient instruction); communication skills, and professional behavior, including independence and initiative. Midterm feedback is provided by the student’s clinical preceptor for the first two weeks, including areas of the student’s strengths and areas in which the student could benefit from further development. Written evaluations from clinical preceptors for both parts of the rotation are them collated to yield a composite clinical grade.

Examinations

There is an NBME multiple-choice subject exam at the end of the rotation. Material covered is drawn a national bank of questions around commonly seen clinical problems.

Final Evaluation

Components of the final evaluation include the student’s composite clinical grade, performance on the written test, and student presentations in the preceptor group (clinical questions and family systems project). Students will be advised at the outset of the rotation as to the relative weighting of these components.

Informal Guide to Family Medicine

This clerkship is a refreshing and supportive clinical experience. It requires the student to read-up on a broad range of topics, and use almost every physical diagnosis skill taught during the second year. It also may be one of the few opportunities where students are encouraged to explore psychosocial issues and their impact on health, and are required to include health education as a part of each patient encounter. Where you place FM in the course of your year, while not critical, can determine a lot of what you are able to glean. The amount of depth you need to know for the rotation and the final is less than that of the other rotations. On the other hand, the breadth of this rotation literally encompasses the rest of the year. You might imagine that doing this first might be overwhelming because you are asked to learn the basics of every field in one short month. The later you do this rotation in the year, the more experience you will have under your belt. Be sure not to do this one last though if you think you might want to do FP - many such students are unable to form their final opinion on FP as a career until they do it and if you’re one of these people it might help to figure it out earlier!

The Surgery Clerkship

Director of Medical Student Education, Surgery

James McKinsey, M.D. and Kerstin Stenson, M.D.

Surgery Student Program Coordinator

Antonetta Sarro

Office of Medical Student Programs, Surgery

Billings Hospital, Room 0-234, 702-6337

The Surgery clerkship is divided into three phases: four weeks of a General Surgery service, four weeks of subspecialty service (may include two weeks of Anesthesia), and two weeks of outpatient surgery. Student preferences for specific General Surgery and surgical specialty services are solicited prior to the start of the quarter. Every attempt is made to accommodate reasonable requests, but it is unlikely that you will have all of your preferences filled. Requests for changes in the rotation assignments are subject to approval by the Director of Medical Student Education.

At the University of Chicago Hospitals, there are four General Surgery Services and a large number of Surgery Subspecialty Services each with a corresponding inpatient and outpatient rotation. Each of these services handles patients with diseases classically associated with General Surgery or the Surgical Subspecialty area. However, there are various emphases from service to service, and you should familiarize yourself with these subspecialty emphases if you have a particular interest in such areas as breast surgery, transplantation surgery, endocrine surgery, etc. You may also choose to do General Surgery at Weiss Hospital, or MacNeal where the service is more general and students have an opportunity to see a more diverse spectrum of cases.

The Third Year student is considered a part of the team and is encouraged to participate actively in ward rounds, inpatient care, outpatient clinics, and the surgery of patients on his/her service. You are encouraged to do outside reading and to attend the various weekly Surgical Conferences. A Tuesday afternoon lecture series is held at the University of Chicago Hospitals for all students. You also participate in case presentations and surgical pathology sessions at both sites.

Students are evaluated at the end of each rotation by attending faculty and residents on the service. The evaluation forms are then placed in the student’s file which is located in the Surgery Education Office and may be viewed by the student at any time during regular office hours. At the end of the clerkship, students are required to complete both an oral and a written examination. A final composite evaluation form is completed for each student, containing the final grade for the clerkship and narrative comments. The student is encouraged to review his/her progress with the senior resident or attending physician on service. The Director of Medical Student Education is also available to counsel and advise students.

Clinical Evaluation

A student’s clinical performance is evaluated and graded by the residents and faculty who work with the student on each rotation. They are asked to evaluate the student in several areas, including clinical acumen, interpersonal skills, and general knowledge. Written evaluations, usually with an accompanying letter grade or a Pass, are submitted to the departmental Office of Student Programs. A composite clinical grade is determined from these evaluations.

Examinations

There is an NBME Subject Exam (comprehensive multiple-choice) and an oral examination at the end of the quarter. The half-hour oral examination is conducted by an attending at U of C or MacNeal and consists of patient management questions as well as general anatomy and physiology questions pertinent to the study of surgery. The written examination is reported as a percent correct figure and then converted to a letter grade using a standard scale. The oral examination is graded as Honors, High Pass, Pass, or Fail.

Final Evaluation

As in other rotations, the level of a student’s performance in the third year is reflected in the clinical evaluations and the written and oral final examinations. The surgery department is extremely well-organized and will provide you with a printout of compiled evaluations and exam grades at the end of the quarter. A student’s overall performance in Surgery is reviewed by a faculty committee which meets during the Winter Quarter in order to nominate senior students for Graduation with Honors and special awards (see Section on Graduation with Honors, AOA, and Awards). These designations usually reflect significant work in surgical research. In the rare circumstance that a student receives a failing grade, arrangements will be made to have him/her repeat the clerkship.

Informal Guide to Surgery

This rotation has a vague military feel to it. Maybe it’s the crack-of-dawn starts, the emphasis on action, the predominance of men, and the prominence of hierarchy. It is certainly a rotation in which you will work long days and get a good inside look at your fellow human.

Surgery is a "kinder and gentler" rotation than it has been in the past. This is due to the outpatient weeks, where again hours are roughly 9 to 5, Monday through Friday, with no call. A word of warning to those who do Surgery as your first rotation: in past years a significant number of students who did surgery first have done splendidly on the wards but miserably on the final written exam - there is a significant medicine component on the exam, so brush up on your medicine as you go along. Enjoy!

The Perioperative Medicine and Pain Therapy Clerkship

(aka "Anesthesia")

Director of Student Medical Education

Jerome Klafta, M.D. 702-9922

Half of you will take this clerkship during your Surgery Clerkship third year, and half of you will take it during fourth year. You will be able to specify your preference of the two times, and an effort will be made to accommodate your request.

This two week long clerkship is conducted at the University of Chicago and at Weiss Hospitals and will provide exposure to the following: risk assessment, ambulatory cases, emergency cases, local and general anesthetics, sedative, hypnotic and analgesic agents, noninvasive and invasive monitoring, postoperative management, acute and chronic pain evaluation and management, treatment of obstructed airway, treatment of hemodynamic instability, and blood product transfusion. Students will also have the opportunity to observe or perform procedures such as endotracheal intubation, intravenous cannulation, and central line placement.

Most third-year students find the anesthesia rotation to be a pleasant respite from the time spent on the other side of the OR curtain. Most fourth-years on the other hand find this to be a necessary evil and a rude interruption of time that might otherwise have been spent on a beach. Regardless, the anesthesia people love to teach and are thrilled to have students working with them.

Evaluation

You will be evaluated by attending physicians on diagnosis and management in perioperative medicine, including basic risk assessment, interpretation of noninvasive monitors, incorporating pharmacological principles, and explaining treatment goals and strategies. Students will also be evaluated on communication skills and professional behavior.

Some Things to Think About Throughout the Third Year

Residency Application and the Match

The Dean of Students’ Office holds a meeting for all junior students in early May in order to discuss and distribute information concerning the National Resident Matching Program (NRMP). All necessary forms, as well as a booklet explaining the NRMP, are distributed at this time. A general timetable for events associated with the NRMP is provided. The schedule is intended to give students a general idea of the timetable and kind of information required.

All students who will be receiving the M.D. degree the following year are strongly advised to enter the NRMP, even if they are uncertain about entering a residency program or are intending to enter the military match. Students should be aware that several specialties have a separate match and an early match date. These specialties are Neurology, Neurological Surgery, Otolaryngology, Ophthalmology, and Urology. Residency programs in the Army, Navy, and Air Force also do not participate in the NRMP. Students should seek advice and information from the Dean of Students’ Office and their faculty advisors about these programs.

NRMP Timetable

End of July--Curriculum Vitae and personal statement for "Dean’s Letter," NRMP agreement and fee due in Washington, DC.

August-September--Applicants request residency materials directly from hospitals. Students request letters of recommendation from faculty. The majority of students will enter the residency application process through ERAS (Electronic Residency Application Service). The Dean’s Office obtains a special transcript form and application information is scanned through the Dean’s Office Work Station. The advisor’s paragraph is submitted to the Dean’s Office.

End of September--Final list of hospitals for applications due in Dean of Students’ Office.

Start of November--Dean’s Letter is sent to hospital residency programs. This is the earliest date permissible for the release of the Dean’s Letter.

December-January--Students arrange residency program interviews.

End of February--NRMP must receive final confidential Rank Order List by this date from students and hospitals. The Match begins February 27th.

Mid March--Notification of unmatched applicants on the day prior to Match and....MATCH DAY!!!

Planning for the Year Ahead

The Dean of Students’ Office runs a three part series for third years during which some of the major issues of the fourth year are introduced and discussed. A list of topics and the months in which they will be discussed are listed below.

March General class meeting on the elective system and planning for year four.

April General Class meeting to discuss the Dean’s letter process, curriculum vitae, personal statement, letters of recommendation, and interviews. Also a general class meeting to discuss the National Residency Matching Program and non-NRMP match processes.

Career Counseling and Planning

Also refer to section on this topic in the first part of this book. In addition there are various other opportunities for you to begin planning your career.

Presentation Series on Various Specialties. This presentation series involves formal presentations by representatives from most of the residency programs at the University of Chicago Medical Center about their specialties and the residency application process. Although these presentations are oriented toward sophomore and junior students, they are open to all. Individual notices are sent out to student via mail boxes. The presentation series is usually conducted in the Winter Quarter.

"Career Day" Programs. Another source of information on potential career choices are "Career Day" programs. These programs are usually one- or two-day sessions put on by groups like AMSA, AMWA, and the AMA to help introduce medical students to various medical specialties. Notices about "Career Day" programs are posted in the medical student lounge or sent to students’ mailboxes.

Medical Alumni Association’s Residency Search Guide. The Medical Alumni Association provides current students with a computerized list of alumni and their willingness to provide various sources of information or personal assistance including: whether a student might stay over, willingness to discuss hospital residency locations, and information related to residency and career aspects.

A Few Closing Notes

Call

The meaning of call varies widely from clerkship to clerkship and from institution to institution. In general, call is both exciting and dreaded. It is a wonderful time to learn on your feet if you have a good resident, but it can also be torture when your pager goes off at 3:30 A.M. and you know you won’t be getting any more sleep. During the Medicine clerkship at the U of C, call means staying in the hospital to admit and work-up one to two patients every fourth night. Theoretically, you can go home after two admits, but sometimes you are there for the night. On-call beds are provided for medical students in the student lounge (some students will simply stay up all night and some go home at 4 A.M. and return for morning rounds). Occasionally, it is possible to find a spare bed in the residents’ call rooms.

Inpatient Pediatrics call is similar at all the training sites; you typically remain in-house the entire night. The hospitals will provide you with a bed if you stay the night.

OB/GYN call basically involves hanging out in the hospital or at home hoping that the ER resident will (or will not) page you and sometimes admitting a patient.

Psychiatry call, at all training sites, is usually once or twice a week, and involves seeing and admitting ER patients with the resident on call. At the U of C, you usually stay until 10 pm or midnight.

Surgery call is the most variable. It ranges from none to every sixth night, depending on the service and your interest. You don’t admit many patients; you generally just follow the intern around. At the U of C, your sleeping options include: (1) borrowing a call room key from an intern and trying to find a spare bed, (2) sleeping in the medical student lounge call beds, (3) sleeping in a patient lounge and (4) not sleeping. Sheets and other supplies may be obtained on the ward or at various other clandestine locations, and you can arrange a wake-up call with the page operator.

The Hierarchy

The attending is the big cheese on the team. They call the final shots and they call your final evaluations. Some attending faculty will make a big issue of this, others take a backseat role and allow the residents, especially the senior resident, to lead the team. Other attending faculty don’t recognize your existence. Regardless, blatant brown-nosing is neither necessary nor desirable, but it is worthwhile to be in tune with the attending’s biases. In terms of dealing with the house staff, you sometimes walk a fine line between working for educational purposes and doing pure scut. If you frequently cross that line or feel you are being abused, discuss it with them. It may simply be a misunderstanding. Remember, you aren’t evaluated by interns. Finally, be nice to the nurses and ward secretaries; they can make life harder or easier for you.

Lectures

If nothing else, lectures are a reason to take a break, eat lunch, and socialize. Often, they are good, and some are very helpful for the exams. You can survive with missing a few (or all as some people have done). And if you are sleepy, don’t sit up front unless you want your REM disturbed by an annoyed lecturer.

Student Morale in the Third Year

Third year is an amazing time. You get your first taste of medicine, the hustle and bustle and the excitement of helping the sick. You see life and death first hand and have the opportunity to really make a difference for some patients. At the same time, third year can really get to you at times. Lack of sleep, feeling useless, patients sick and dying and your own usual emotions and difficulties to top it off. When it happens, take a step back and realize that it will pass and that better times are ahead with the next day or next attending or next rotation. Remember H. A. L. T.: Never get too Hungry, Angry, Lonely, or Tired. Reward yourself, even if it means tossing your books for a few hours. Call a friend or relative, go to a movie, go to a bar, exercise, eat a decent meal, or get a good night’s sleep. When it’s all over, you will wonder why you ever worried in the first place. Good luck!