Top 10 Ways to Ace Your Away Rotations

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Why settle for being average, when you can be the best version of yourself? Take advice from those who know how to shine on EM away rotations – because when 4 weeks of your time might dictate the next 3 to 4 years of your life, you want to make sure to cover all bases. We’re offering tips from 3 great sources – a program director and two recently matched fourth-year students – to help you make your best impression during your away rotations.

 

MSC - Away Rotations - AdamKellogg_OnlineAdam Kellogg, MD, FACEP
Associate Residency Director
Baystate Medical Center & Tufts University
Chair, CORD Student Advising Task Force

1. Bring your A game.
Away’s can count more in your application than your home rotation (because these are not your established advisers, their opinions can be perceived as less biased).

2. Know what you need to work on.
If you have done a previous rotation (and usually you have), make sure you learned from them where you need to improve so you can tackle those things early.

3. Polish your presentations.
So much of the evaluation of your skills is going to come from how you present, that it is worth giving this a lot of attention.

4. Build your knowledge base.
Reading a thousand-page tome of EM knowledge is not realistic during the summer of your fourth year; HOWEVER, reviewing one of the concise rotation review books is doable, and these usually cover the knowledge your evaluators expect you to have.

5. Find out about letters early.
Each program handles letter writing differently. Figure out early on how they do this: group letters? Individual SLOEs? Traditional letters?

6. Ask for help.
You are not going to know their system or the layout of their ED. You are better off asking for help early than stumbling around and wasting time trying to figure out where the suture kits are kept or how to consult surgery.

7. Be proactive.
Go in with the team for sick patients and codes, ask what you can do to help, and volunteer for procedures.

8. Be honest and avoid inflating your experience.
If you have never intubated, tell them. They may still let you try.

9. Bring your own stuff.
Don’t assume they will have scrubs or trauma shears for you to use. Bring your own.

10. Own your patients.
Expectations will vary from one program to another, but if you want to earn the ultimate compliment (“It was like having another intern on the team”), then you need to manage your patients – including following up on test results and response to treatment, doing discharge and admit paperwork, and making consultant calls. Ask for these opportunities to prove yourself.


MSC - Away Rotations - DruMorgan_OnlineDru Morgan, MSIV
Lincoln Memorial University – DeBusk College of Osteopathic Medicine
Matched, Emergency Medicine at Charleston Area Medical Center, Charleston, WV

 

1. Don’t be lazy or cut corners.
Auditions are not the time for brevity in your history-taking or physical exam. Be efficient and focus your process, but don’t miss important things that will later make you look bad. For example, if you suspect sepsis in an elderly person, a good source may be the skin. Now is not the time to avoid exposing your patient entirely; grab a nurse and tell the patient and family you need to evaluate thoroughly for any signs of infection. Going the extra mile without being told to will make you stand out.

2. Be on time.
Many of you would be surprised how often students on auditions are routinely late. Show up and be ready to go when the shift begins, just as we have all been taught. You will learn more and impress more if you’re there for any departmental sign-out at the end of shift. By showing up even earlier you might be able to ask the resident coming off shift for more information on the patients – and get more face time with them as well.

3. Never lie.
If you neglected to ask a question or neglected to do part of the physical, just say so. This should be a given, but it needs to be clear: Lying to make yourself look good does not trump patient care. Some of the residents will place a lot of trust in you, and if you say you did something and found normal results, they may not go behind you to check again. If you lied about what you did, then you have now sacrificed patient care for personal gain.

4. Take ownership of your patients.
Your goal should always be to know as much or more about the patients you saw than the resident. You should try to stay on top of your patients and apprised of lab results before the resident is. Doing so will make you appear more like an intern than a student.

5. Do simple and complex procedures.
If you’re sitting around in the documentation area for any extended period of time, you probably are not doing enough. Auditions are not only the time to make an impression, but also a great time for you to learn. After all, above all else you’re there as a medical student. Make opportunities to start IVs, get ABGs, place OG or NG tubes, insert Foley catheters, repair lacerations, and more. These are skills you may not get on any other rotation, and your initiative will be noticed by all.

6. Be on the nurse’s side.
We have all heard it a thousand times: the nurses can either make or break you. Use the nurses to your advantage, and build rapport with them. You can do so by making their jobs easier. Gather your own supplies if you can, clean up your own patient after simple procedures like rectal exams or lacerations, get everyone who wants one a warm blanket or drink, and slowly the nurses will become your biggest advocate. This will not only make your month more fun and successful, it will also help you successfully match. Their opinions matter more than you know.

7. Be teachable and re-teachable.
Most any program in the world can provide you with an adequate emergency medicine education. However, they can only provide it if you’re willing to learn. Ask intelligent questions when you have them. Avoid the very bad habit of asking questions you know the answer to just to impress the resident or attending – everyone knows when you’re doing this. Make a note of any pearl you’re taught. Ask questions later to solidify your understanding of a topic that was discussed. Avoid saying things were done different or better at another facility or you believe the resident or attending is wrong. Being re-teachable is just as important.

8. Stay on your feet.
The greatest thing you can do for yourself while on auditions is try to keep moving. A constant commendation I received was that I always seemed to stay busy. Be the eyes and ears for your resident, and check on the patients as often as you can. How are therapies working? Any new symptoms? Has the pain resolved? Any questions for the physicians? One caveat: Some patients will take advantage of this and bombard you with requests every time you enter the room. Recognize when this isn’t the right thing to do in some situations.

9. Don’t overstep your boundaries.
Often on rotations I saw students, including myself, unintentionally overstep boundaries. Sometimes it could be as simple as saying, “Yes ma’am, we can give you another dose of the medication before you leave.” This becomes problematic when the resident or attending doesn’t agree and you’ve set the expectation with the patient. Don’t break bad news to patients’ families on your own, even if you enter a room and they ask you to. Lastly, if you enter a room and can tell the patient needs intervention sooner than later based on vitals or presentation, do not be the barrier to their ultimate care. Excuse yourself from the room and let the resident know the patient should be seen right away. In all of these situations there’s only one person who risks looking bad: you.

10. Be humble and be yourself.
On auditions you should work very hard. In the process you should not work hard to be someone else. Trying too hard to change personality or change the way you approach patient care will ultimately show, and in the process it will exhaust you. Just be yourself, work hard, and act as an advocate for both your patient and your resident. Stay one step ahead, be humble, be kind to everyone, and success will surely follow.

Bonus 11. Work on your presentations.
The emergency department presentation is unique, both in sequence of content and brevity. (Watch the great video tutorial here!) With each new resident and attending, be thorough at first. If you’re too long-winded they will tell you, and you can tailor to their style. Remember the stepwise fashion you were taught in medical school, but interject important details where they fit best. Never shortcut your plan; state everything you want to order for the patient and why. Not a “CBC, BMP, CXR, and Tropomin,” but a “CBC for anemia, BMP for electrolyte abnormality, CXR to evaluate mediastinal widening, and Troponin to begin the rule-out process for MI.” This level of thinking in your presentations will make you look more like an intern and less like a fourth-year.


MSC - Away Rotations - MichaelSpigner_OnlineMichael Spigner, EMT-CC
Hofstra North Shore-LIJ School of Medicine
Uniondale, NY

 

1. Give 100%, not 99%.
This sounds intuitive, but consider what it means to give 100%. Treat EVERYONE with respect (from the person ringing up your coffee to the nursing staff – perhaps especially the nursing staff). Take pride in looking professional. Show up early. Stay late. Limit your breaks. Know every detail about your patients. Don’t disappear when something important is happening. Call family for collateral. Volunteer for the jobs that nobody wants (Yes, that means doing a lot of digital rectal exams and guaiac tests). The difference between 99% and 100% is all of that stuff besides direct patient care.

2. Be honest.
If you break this rule, you’ll be in hot water. It takes a lot longer to build trust than to break trust. If you don’t know something, own it. If you didn’t do something, own it. If your house of cards falls down early in the shift, you may not get a second opportunity to redeem yourself. Worse yet, if your dishonesty leads to a negative outcome for the patient, you may never live it down.

3. Facilitate the completion of your patient’s plan.
This is big. Emergency medicine is all about efficiency. When you meet your patient for the first time, you should already be thinking about their disposition. Will they require a consult? An admission? Observation? Once the patient’s plan is laid out, make it your duty to expedite this plan. This will earn you BIG points with your attending and will make you stand out considerably from the pack.

4. Know lab values before your attending does.
This is a proxy for knowing your patients and their course well. It is better to take fewer patients and watch them like a hawk than to try to impress an attending by taking more patients and doing a suboptimal job with them.

5. Don’t be a pain.
One of my strongest evaluations cited the ability to be helpful without “getting in the way” during an extremely busy shift. Attendings have an obligation to teach, provided that it doesn’t interfere with patient care. If you have questions, save them for the lulls between the action. When your attending is busy, find something helpful to do rather than following them around like a lost puppy.

6. Have the right attitude.
You’re doing this because you want to, right? Nobody wants to work with someone who complains, appears bored, or is too demanding. If this is what you want to do, you should be happy doing it (all of it). Signs of disinterest or laziness are major red flags to any evaluator.

7. Make the residents look good.
We all know you’re trying to put on your best face, but sometimes it’s best to take one for the team and let someone else have the credit. Don’t ever make a resident look bad, unless you’re begging to be strung up when you make an (inevitable) mistake. Don’t be surprised if the attending grading you asks the residents for their opinions about you.

8. Treat the other sub-interns with respect.
Remember, they are on the same path as you. Someday, in the not-too-distant future, they may be your co-interns. If you burn your bridges now, you may not have someone backing you up when you’re swamped or need to swap shifts. On the flip side, the connections you form during your rotation and subsequent interviews may persist beyond the application process. If you’re interested in academics, the network you build will be one of your strongest assets. Don’t be shortsighted!

9. Read about your patients.
I was coming off a night shift one time and running the list with the oncoming team. In reference to a patient with renal colic, the attending cited a Cochrane Review regarding alpha-blockers as medical expulsive therapy for ureteral stones. It just so happened that I had the summary of that exact review folded in my coat pocket. That was an awesome feeling. It never hurts to read more, and you’ll never receive an evaluation that says, “He/she has read enough.” Use each clinical question like a focused educational opportunity. If you see a similar patient again during your rotation, you’ll look like an all-star if you’re up-to-date on the literature.

10. Don’t stampede over procedures.
We all love to do procedures (that’s one of the reasons we picked EM), but as one of my mentors told me, “You can teach a monkey to do a procedure.” Sticking a needle into a big pocket of fluid may feel good, but it does absolutely nothing to distinguish you as a strong residency candidate. You will have your time to torture patients with your poor dexterity, and that time is residency. For now, feel free to take procedures that are offered to you (or are uncontested). Just don’t cause a ruckus over it, and definitely don’t waste time doing a procedure on another patient if your own patient needs your attention. If you are going to do the procedure, make sure you know the indications, contraindications, complications, and utility of the test.

Sean Ochsenbein, MSIV

Sean Ochsenbein, MSIV

East Tennessee State University Quillen College of Medicine, Johnson City, TN; @OchsenbeinMED
Adam Kellogg, MD
Adam Kellogg is an Associate Residency Director at Baystate Medical Center/Tufts University School of Medicine and Co-Founder of www.EMadvisor.blogspot.com. He is also a former Emergency Medicine Clerkship Director.
Michael Spigner, EMT-CC, MSIII

Michael Spigner, EMT-CC, MSIII

Hofstra North Shore, LIJ School of Medicine, Uniondale, NY
Dru Morgan

Dru Morgan

Dru Morgan, a fourth-year student at Lincoln Memorial University - DeBusk College of Osteopathic Medicine, matched in emergency medicine at Charleston Area Medical Center in 2016.
Dru Morgan

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