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Advice to students on rotations...

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Hi Gang,

I tend to do some reflecting on this crazy process of learning medicine and every once in a while I come to a realization I think is worth sharing.  The past few months I've been thinking about rotations...


There is really so much that goes on during rotations.  You try to learn your way around a new hospital, you try to learn the job/responsibilities assigned to you, and you try to learn the basic textbook medicine related to that specialty so that you can cram it in your head for your EORs. Now that I have graduated, however, it has become abundantly clear that when practicing on our own and making our own decisions, it requires much more than those things.  Since I am doing a residency program, I still have to opportunity to do rotations and I have found myself changing the way I approach my learning while on a rotation.  More and more I am asking myself, 'what will I need to know about this once I am in practice in my own specialty?'.  The basic outline is as follows:


General Learning Goals for Rotation on Specialty X... 

-What are the most common chief complaints and diseases for this specialty.  Learn textbook knowledge about these.

-The perspective/approach with which the specialist thinks about and works through the chief complaint.

-Really practice the ddx, widen it, and internalize it by seeing as many cases as possible.

-The history questions that really target the ddx, and what is the best way to ask these questions (learn this by listening to the way the specialists ask questions).

-The systematic physical exam, the technique, and getting a feel for what pathology looks like and feels like.  Also, how do they objectively describe and document their exam findings?

-The orders for workup.  Getting a sense for sensitivity and specificity of these tests.  How much weight does the specialist actually put on the results of these tests?  What is the systematic approach to reading the studies (ekg, cxr, head CT, etc) and practice practice practice with the specialist while you still can.

-The most common treatments used in this specialty.  What are the things that the specialist has in the back of their head when they order this?  Chart checks they do before ordering (pmh, labs, etc), C/Is, interactions important enough that they bother memorizing, common side effects and worrisome adverse reactions they know to look out for.  

-How to perform the most common procedures of this specialty, and lots of practice doing them. 

-When is it appropriate to refer these patients, what do they want us to do first, and how do they want to hear the consult/presentation?


As you can imagine, its not possible to learn it all when you are on your rotation.  So, its really important to prioritize, and this is the second part of my realization: the most important things to learn on rotations are the things that you'll have the most difficulty learning while practicing on your own.  


You'll be able to look up the majority of the above things like ddx, history questions, orders, etc.  However, reading 10 articles won't come close to the experience of having your hands on a patient with a peritonitic abdomen, an extremity with compartment syndrome, etc.  With this in mind, on my current rotations I have been focusing much more on honing my physical exam skills and truly trying to internalize what abnormal looks and feels like.  Another example: if you want to commit to memory the most important "take away" points for a given drug, good luck searching a textbook or uptodate... you'll just find lists of side effects and contraindications a mile long which will be next to worthless.  With this in mind, I now realize that my preceptors/specialists have 'lived and breathed' these medications for years, and have internalized the most important take-away knowledge about these meds.  All it takes is a few good questions and they'll share this invaluable knowledge with you.  In essence, you should realize the value of being immersed in a wealth of specialty knowledge and being in a position where you are allowed/encouraged to ask questions... take advantage of it!  You likely won't ever get this chance again!  So, in the outline listed above, I have italicized the things that I consider knowledge you'll be able to obtain MUCH easier while on your rotation than when you are out in practice.  These should be the things you really try to seek out and prioritize while on your rotations.  


As I said above, with these realizations, I've been approaching my rotations much differently and I think my learning experience has become much more productive as a result.  Instead of passively scanning through a review book, I now have an outline of things I am actively seeking to learn and my retention is much better.  In the past, when my preceptor and I would have down time, I'd try not to bother them and couldn't think of good questions anyways.  I now always have a framework of high yield questions ready for moments of down time and I've been able to learn invaluable information as a result.   


I wish I would have made this realization before starting rotations in PA school, since I think I would have gotten a lot more out of my school rotations.  It is what it is, I suppose.  At the very least, I hope I can pass some perspective on to you students going through it now so that you can make the most of your journey!  


Any other PAs out there have any advice to offer students going through their rotations?  What realizations do you wish you had made before graduating that would have made your learning experience even better?  



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I wrote this some time ago, but -- technology changes aside -- much of it still works:


Rotations for Newbies


Preparing for Rotations




1. Decide that you are on the ultimate “field trip” with the goal of learning all you can about what life is like for a PA in whatever rotation you are on.


2. Even though you aren’t being paid, consider it a job, and one that you would like to keep! (You might actually get a job offer too).


3. These people may play a role in your life later, even if you don’t want to work for them. For example, one day I found my preceptor preparing a recommendation for a student in the class ahead of ours.




1. Buy the second white coat so you always have a clean, IRONED coat ready to go. Patients may have more respect for you if you look like you made an effort.


2. Consider getting a smartphone with the paid version of Epocrates (Essentials Sx/Dx) on it. Best single piece of personal equipment (next to a pen and a stethoscope).


3. Like all disciplines, medicine involves a lot of abbreviations. Consider Beiks Bdicty on your phone  (www.beiks.com) with the “MediAcro” option.  This lets you look up abbreviations (especially in the hospital, which is the home of abbreviations!) without bothering asking even more questions than you need to.  It costs about $25 and lets you know, for example, that your cardiologist’s cryptic remark to his nurse about a “PFO” involves a patent foramen ovale.


4. I’d carry the Tarascon Pocket Pharmacopoeia ($10 from www.tarascon.com).  It lets you quickly look up drug doses, fits in your scrubs, and you won’t cry quite so hard if you lose it (like you would for a lost or broken phone).  It will help you when your preceptor says to write a script for him or her. It also has the advantage of showing drugs by family, which is great when you want to see a list of second-generation cephalosporins or anti-emetics to consider.


5. Maxwell’s little book of documentation formats is a great reference, especially the first time you are asked to write something you've never written before.


6. Carry a pen and 3x5 cards to write down patient ages etc for tracking, as well as your preceptors pearls of wisdom, or messages you get when you call back doctors that have paged him.




1. Try to go to every site some time other than the first day you are due to work. Dress up as if you are on a job interview; I never wore a white coat that day to emphasize that I wasn’t yet working for them. 


2. Ask about things you can do to prepare. The preceptors often gave me references to read (sometimes they even gave me the books too). 


3. This early trip makes things easier on the first day and also set up a good first impression. It also gives you a chance to meet the staff and SEE HOW THE PHYSICIAN DRESSES.


The Rotation


1. Look the part and dress at least as well as your physician does (some of them may not exactly be good fashion models!). Depending on the rotation, that might mean scrubs or it might mean a dress shirt and tie.


2. The preceptors don’t get paid to have you around, so try to send the message that you are interested in the subject matter and will do anything you can to be helpful. Consider it a success if they actually start depending on you to save them some time.


3. If someone says “Would you like to (see a case, see a patient on your own, try a procedure that you have at least seen done once)…”, say “Yes!” If you want someone standing by because you are afraid you might hurt the patient, don’t hesitate to tell your preceptor that as well.


4. If you’re trailing your preceptor around, pretend that you are shooting a documentary on what his life is like (talking to patients, doing procedures, talking to family members, interacting with staff, dictating, filling out paperwork, or whatever.). At any moment, he may start telling you to do something that you could have been watching or listening to him do. 


5. Ask questions, but be sensitive as to when is the best time to do it.


6. Establish relationships with the preceptor and his or her office staff. Get to know each other and try to learn from everyone.


7. Be gracious and thank everyone who helps you. This includes the nurse who will invariably save your butt the first time you try to suture a child in the ER or scrub-in in the OR.


8. You will often come home too tired to crack a book. Make a list of things you didn’t know or need to know more about. Spend some time on the weekends reading up on them.


9. People (including patients) will be interested in who you are and why you are becoming a PA. Have an answer ready!


10. Enjoy the patients. They will teach you a lot and they know more about what’s wrong with them than they know. Often you will be the only person who has the time to listen to them.


After the Rotation


Send a thank-you card to your preceptor. Also to any of the staff who were particularly helpful, and one to the staff as a whole. They did a lot for your education, so show some gratitude.

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  • 1 year later...

A few weeks ago I was reading through the blog posts for one of my favorite FOAMed (free open access medical education) blogs, First10EM.  He has really great content in general, but one of his posts really struck a cord with me, and I think you all should check it out (see below)


His experience was just like mine... lots and lots of time spent staring at textbooks, being talked at by professors in class, and cramming before tests just to be inundated with a new block of information the next day.  I really struggled retaining all the things that we learned. 


"We spend so much time trying to learn medicine, but we never really learn how to learn."   


The truth is, the vast majority of educators themselves don't really know the right way to learn, so its no surprise that we haven't been explicitly taught 'how to learn'. After reading this article, chatting with a friend of mine in education, and doing some research of my own, I think I've gotten at least a brief exposure to some of the *evidence based* high-yield learning techniques.  Its pretty cool stuff that I wish I had known a lot earlier than now, so I figured I'd share 3 of my favorite resources with you all.


Making it Stick article on First10EM mentioned above ---  https://first10em.com/2016/09/26/making-it-stick/


What Works, What Doesn't PDF ---  this is a great read reviewing various study techniques.  --- http://tguilfoyle.cmswiki.wikispaces.net/file/view/What_works,_What_doesn't.pdf


Study Less, Study Smart -- Marty Lobdell's famous lecture -- 




I know it can get really tough as a student with the information flooding in, but hang in there, and hopefully along the way you'll pick up a technique or two that will make your life easier!  




(edit - yikes, the site is having some trouble with the hyperlinks....  hopefully its fixed now)

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