Advice for 3rd year is very difficult to give as each experience is variable as is each students
studying strategy. Below is a description of one AOA member’s approach to the 3 rd year and
advice on how to succeed.
Books: I used one book as a base for each block which I read first adding notes into it like we
did with FA for boards. I did this in order to have one source to review important points the
week of the shelf. For this "base" book I either used First Aid for each specific rotation (not FA
for step 2) or Kaplan notes (there are circulating copies of them). I also used Case
Files and Pretest for each block as well as the Kaplan Qbook questions (also circulating copies).
Again, I am not a text book reader and need to go over things multiple times before they stick.
These aspects of my studying style guided my schedule and choice of books. If yours differs, you
may need to tailor these suggestions to fit your learning style. Here's an example of how I set
up my studying for each rotation:
week 1: read FA or Kaplan notes (depending on what I chose to use as my base book)
week 2: read Case Files - taking notes from case files into my "base" book (what wasnt already
in there, or highlighting important points)
week 3: Pretest questions - taking notes from questions in "base" book (these are generally
harder than the qs you will face on your shelf, which is why I liked them b/c it made the shelf qs
not seem so bad)
week 4: review "base" book with added notes and do Kaplan Qbook questions
Time periods were extended for longer rotations, however longer rotations generally cover
more material so be wary not to get behind. Also I would highly suggest stuffing case
files/pretest into your white coat pocket (fits perfectly in the inner ones) for down time while at
work/on service - some rotations have more than others. In terms of my "base" book I used the
First Aid series for Psych and OBGYN and Kaplan notes for Surgery and Peds. I chose these in
particular because they were short enough that I could review them the last week of the
rotation for the shelf but seemed to cover the most salient points. Rotation specific notes:
Medicine: I read Step Up and didn’t really feel like I got a lot out of it, but don’t have a good
alternative. Maybe blueprints? I would try to get through as many questions as possible for this
block as you will get Qs from every field on your shelf. MKSAP questions with explanations
were very good. Kaplan Qbook has 8 tests (400 qs) and if you do those along with mksap you
should be in a good spot (although I didn’t and don’t know if this is possible with
time allotted for studying). I hadn’t yet gotten into my pretest groove for this rotation so I’m
not sure what to tell you about those questions. This is a long rotation but be sure to pace
yourself with studying, there's a fair amount of material covered.
Surgery: When on service I would try to look up the cases I was going to scrub for the next day
(if you're here Charity or the new person who serves as Charity will send the schedule out, if
not ask your chief) and briefly looked up indications, contraindications, complications, relevant
anatomy for the next day. A good resource for this after "surg recall" and your kaplan/FA notes
are the specialty specific electronic books found as links on our library website listed under the
"electronic books." Once you've done this for a few on each service, you will see repeat cases
and won’t have to do this anymore so you'll still have time to study. I used NMS surgery
casebook instead of case files, but have no recommendations for or against this approach. I
ended up loving the case files series and didn’t think NMS was stellar, but I read it instead as
the previous 4th yrs told me they thought the case files for surgery was the weakest of the
series. I think NMS may be more detailed in its discussion and breadth of cases when compared
to what I know about the case files series. I also did questions from appleton and lange but
thought they were too short (unlike the shelf questions) and were too straight forward. The
shelf is heavily weighted in the medical management of patients perioperatively and trauma
considerations.
Psych: Very straight forward and our second yr classes prepped us well for this rotation. Do a
lot of questions b/c the diagnoses can have subtle differences that are sometimes hard to pick
up on with the first pass.
Family: There aren’t any Kaplan notes for family so I just used Blueprints as my base book.
There are also no Kaplan Qs for family or distinct Qs from USMLE world (they're both merged
with medicine) but I thought pretest was enough for the shelf.
OGBYN: Again I think questions is the name of the game here. I would definitely do the UWise
questions they recommend. They are solid and supplement the Pretest Qs well. I would also
definitely read through blueprints for this rotation as it is the best of the series. This translated
to one book per week (wk1 -FA, wk2 - blueprints, wk3 - case files, wk 4 - UWise Qs, wk 5 pretest, wk6 - review).
Peds: nothing really unique.
On the Wards:
One of my first attendings during medicine (my first rotation) said this and I think it really put
into perspective what was expected of medical students as we advance through the clinical
years. He said that each year our role progresses through the acronym R.I.M.E = Reporter (3rd
yr), Interpreter (4th yr/Intern), Manager (resident/senior), Educator (senior/attending). This
meant that at beginning of third year we should be proficient at gathering information and
reporting it (the S&O part of the SOAP note). Throughout third year we would become better at
interpreting the gathered information and formulating a plan (the A&P). For now this means
you should get proficient at thoroughly gathering information while taking a stab at interpreting
it and formulating a plan. You will get better at asking the important questions/looking for the
important signs as you progress through third year and experience will help you know what is
important on your presentation, but for now just focus on being thorough. Your
attendings/team will further guide you with their questions and suggestions.
In terms of reading up on your patients, if you encounter something you don’t know or you
need to brush up on go ahead and find an uptodate/NEJM article about it but otherwise don’t
go crazy. I pretty much started third year looking stuff up on every patient because I thought
that was what was expected. I feel as though I wasted a lot of time reading detailed articles
when I should/could have been reading to learn the general principles. However, bringing in a
pertinent article for your team/for rounds on a particular subject is a great way to impress your
team and show your interest. Bottom line: you should be looking stuff up, just put general
studying first and don't go overboard.
Never be afraid to ask to do more in terms of patient care. If you want to go see a patient,
perform a physical on a patient with abnormal findings, or do a particular procedure just ask.
This is your opportunity to learn and everyone knows that you are paying the big $$ for
this. You will learn much more from hands on experience than from shadowing. Now is the time
to experiment and try things you never thought you might get to do without consequence if
you are unsure of what you are doing or perform something incorrectly. So dive right in and get
your feet wet (hopefully not with blood).
Things I wish I knew about presenting when I started third year: Your "assessment" is extremely
important as it ties everything you have said together. Be sure to mention all salient points
leading into your plan (ie POD #2 s/p herniorrhaphy with +BS and flatus if you want to advance
diet in your plan). Also your assessment will remind the team/attending of what you have just
gone over as attention spans wax and wane through presentations (esp those 20 min medicine
presentations) and they may not have caught everything you said. As you get better at
presenting you will start to paint a picture with your S&O part demonstrating the pertinent
positives and negatives of the history/physical/labs based on your differential and leading
towards your plan. Again, this is what you should try to work towards but not what is expected
of you at this point.
Pimping: At first I was afraid to be put on the spot in front of a team and thought that if I didn’t
know the answer it was going to reflect poorly on my evals. I then realized what the purpose of
pimping was. They are attempting to get you to think like a physician and pass on pertinent
teaching points with their questions, not embarrass you. 1/2 of the time they don’t even expect
you to actually know the answer to the question, but get excited about something they think is
important that most people might overlook or not consider. Take it as an opportunity and a
learning tool instead of a challenge to your intelligence. If you get something wrong or miss
something (which you will), you will remember it much better than if you were never put on
the spot. Speak out loud as you think through their question - this will show them what you
DO know (even if you don’t get to the right answer) as well as demonstrate your thought
process.
Some things to consider as you progress through third year: always ask yourself "why/what"
when coming up with an assessment and plan (why did we order this test - what are we going
to do with these results?, what is on our differential diagnosis/what is most likely? what are we
doing to rule in/out our top conditions on our differential? why are we treating with this abx what are we covering for? What is the next step? What labs are we/should we order, why? etc.)
This is how you should be thinking when you're responsible for the pts as an AI, and is how you
will start "interpreting" what you have gathered in order to formulate your plan.
Some specific things that I picked up at the end of my 3rd year which will impress your team if
you consider early on:
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Lines - be aware of what lines your pt has (central, IV, NG), why they were placed, and
how long they should stay in/when they could come out (as you are aware every day a
line is in is a greater risk of infection so this is very important to keep thinking about
each day and ppl can often lose track of them)
Lab schedule (look this up under orders on powerchart- ie BMP ordered qAM) - do you
need daily BMPs - what are you looking at with the labs, what will the results tell you?
this will help you decide when you should increase/decrease what you are running
based on what your are testing for on your differential/what you are monitoring
Diet - TPN, NPO, softs, clears, diabetic, etc. when to advance, when to alter
Dispo/discharge - what social services are needed, what needs to happen for this
patient before D/C.
Sometimes it is very helpful to think of/present a plan based on systems- especially with
complicated patients that need many tx in different areas (ie CNS, CV, Heme, ID,
FEN/GI, Renal, Lines, Labs, Dispo, etc.)
What do you do when rounds are over/cases are finished? Whenever there is down time,
always asking the team if there is anything you could do to help goes miles. In doing so, you will
learn what is important in patient management (contacting outside physicians, updating sign
outs, checking up on labs/tests, planning for discharge, etc.). Also as you progress through third
year you will become an integral member of the team, accepting more responsibility, which
means that what you actually do will start to matter. Therefore when the team gets
comfortable with your skills they will ask you to do things that will actually be helpful and
purposeful to patient care which is where you will learn how to fully manage patients. In
addition, if there isnt anything that can be done, this will also afford you a way off of work/time
to study if they say 'no'. This is usually how I started to ask to leave or if it was too early for that,
just sit and read the book I had with me.
When they tell you to leave - do it! It took me a while to accept the fact that this was not a test
of my will to learn or dedication to the rotation/team. Mostly they are saying that the
education you would receive from staying is less than that you would gain from studying so
take the opportunity to bounce and get your study on/enjoy your afternoon/evening off.
Affiliate site rotations
I remember the unease of having to leave and not knowing what I would need at each site. I
just thought I’d give you a few essentials that you should bring wherever you go:
- power cords/extensions
- extra lamp/clip on light - lighting can be very poor at some locations
- shower shoes/flip flops for dorm living
- your own sheets/blanket/pillow
- lock (potentially useful if roommate unknown)
- alarm clock
Attitude: Having known what I want to go into from before med school started I can attest to
the fact that when going through some of these rotations it is hard to stay motivated and
excited about what you are doing, especially when you know you won’t need the expertise
once you graduate. Just remember as you go through each rotation, the purpose of medical
school is to become a well rounded physician while residency is to become proficient in your
field of interest. If you know what you are going into, there are aspects and teaching points
from each rotation that will apply to your future career. Focus on the positives and the
pertinent fund of knowledge and it will get you through rotations you may not be interested in.
There is nothing worse for a team or an attending than a student that doesn’t try or doesn’t
show any interest. I’ve been on rotations with students who have taken this attitude and it
brings the entire team down and definitely gets reflected on evals. I can attest to the fact that
the opposite holds true as well - a positive attitude can significantly impact your evals. Asking
questions is a good way to learn, and can demonstrate your thought process to your
team/attending as well as can show your interest and inquisitiveness. There is obviously a time
and place for them (I would generally start low to high - intern upward) but if used
appropriately can be helpful in many ways. Teams are usually impressed with students that are
excited about learning (especially if they know that you are not going into the field you are
rotating through - more true for the 2nd half of 3rd yr). I know this goes without saying, but
third year can wear on you with its long hours and it is important to remind yourselves of this
point when the going gets tough.
Good luck and again feel free to contact any of the AOA members who have provided their emails for
mentorship purposes which can be found on the AOA website!