Electives in America
This is a brief primer on what to expect for medical students looking to do a firm/rotation/clerkship in the US. It does not cover finding an elective, merely what to expect and how you can prepare.
What rotation should I do?
You can divide rotations into two. Firstly, rotations for those who are considering working in America. The main aim of doing these rotations is to impress your attending, who will then write you a Letter of Recommendation. These are key to getting a good residency in the US. You should aim to do these rotations in the field you are going into.
The second type is a more casual affair, perhaps you have always wanted to see the US and will be quite happy to do anything really.
There are a lot of different terminologies when it comes to rotations, which can be bewildering.
Types of Clerkship
- Clerkships: These are core rotations that US students do, for example a clerkship in medicine, surgery, pediatrics etc.
- Preceptorship: One on One with an attending physician, shadowing them and doing their jobs.
- Consult: Students are attached to specific teams such as the renal team who are then called in by other services to 'consult' and offer specialist opinion on their patients. This is ideal for students who know exactly what field they want to do as you will come out with a deep understanding of the speciality.
- Subinternship: Seen as the hardest rotation. Here, students assume the role of an intern (first year doctor) on a team and carry patients, conducting all the tasks of that doctor. Most teams will allocate an intern and a resident to each patient; subinterns regularly replace the intern in these cases. You will admit patients in turn with the other interns and carry your own load.
How long are rotations for?
This is up to the institution but usually each rotation is three to four weeks. Some institutions set a limit on how many rotations you can do with them and some may charge a separate fee for each one.
What is the structure of a team?
This depends on your speciality you have joined, which are termed 'services'. Generally, each service will have multiple teams under it, depending on the size and demand of that speciality. Teams can be designated 'teaching' services that have residents involved in patients' care or 'private' services that are attending run. Teaching services generally pick up more unwell patients that would provide interesting and educational cases for residents and also uninsured or state insured patients who may have Medicare, Medicaid or Blue Cross as examples.
Components of a Team
- Each team will be headed by an attending, that is the responsible physician, equating to a consultant in the UK. Underneath him/her will be a set of residents, who are doctors in training. Depending on the speciality, residency lasts from 2-5 years. Residents are known by the initials R1, R2, R3 etc with the intern (first year doctor, equivalent to the house officer) being generally called the 'intern' and anything above known as a 'resident'.
- There may be a 4th year medical student on your service, who may be referred to as the 'sub-intern' or the 'sub-I' if they have taken on that role. This will be more common on inpatient teams such as internal medicine or surgery.
- There may also be one or two 3rd year medical students as well who will be doing the same job as their UK counterparts, that is to say learning the basics of history, examination and management.
What will be expected of me?
Medical students in the US are considered part of the team. Your name will be rostered onto the signout sheets and you are likely to be given patients to look after. You will be given a high level of responsibility and you will be expected to perform at an appropriate level.
- On your first day, you will have an induction to the hospital along with the other students who are rotating through. During this time, you will be assigned parking permits, ID cards, computer logins and usually given pagers.
- From then on, you will be sent to your team. It is usually the case that patients are spread across the hospital, as there are patient 'floors' rather than patient wards. Some floors may be dedicated to a certain service, others may contain general beds.
- It would be advisable to page your resident on the team you are joining and run through what is expected of you then and there, noting key points such as what time signout is (this is where the night doctor will sign out your patient to you, assuming responsibility), when morning report is (this is a daily teaching exercise, for example at 8AM, when interesting cases are presented and discussed) and when the resident rounds and attending rounds are. The next item of the day will be noon conference, which is again teaching at noon on a clinical case that usually involves free food!
- The key point to the above is knowing when morning signout is. You will be expected to 'preround' on all your patients before resident rounds. This involves seeing the patients' nurse to find out any overnight events, checking lab tests, imaging and consults from the day before that have come in, seeing the patient and examining them and writing up a progress note in the SOAP format. I allocated 20 minutes per patient for this and it was a push, so it requires advanced planning. Sometimes you will have to split prerounding before and after signout if you have many patients.
- After you have prerounded your patients and have written a SOAP note, you should do a problem based assessment and devise a management plan for the day. After this, it is likely your resident will want you to run the plan before them in order to check over your plan before the attending rounds. Legally and for billing purposes, the resident will have to sign off on your note with something like 'I have seen and examined the patient and I concur with the above plan'. You will also update your electronic signout that gives a summary of the patient, their problems and tasks to do continously through the day. I will give an example SOAP note shortly for an example patient.
- You will be expected to have done a complete focused examination and devised a sensible management plan, especially if you are a subintern. Be prepared to defend this infront of the attending during rounds.
- On consult services, the day will be much the same. You will preround on existing patients, discuss them with the fellow (someone who has completed a residency and is pursuing subspecialisation) or the attending. In the late morning, or afternoon, you will go see new consults called in either alone or with the fellow/attending and devise management plans. Depending on the hospital, the consult service may not carry out new management but merely drop of 'recs' or recommendations in the chart for the parent team to followup.
Rounding and Orders
During rounds, you will either do a table based runthrough of the patients or do a walking round. When it comes to your patients, give a 'one liner' summary of the patient to set the scene such as:
John Smith, a 49 year old Caucasian gentleman, with a history of CAD and Type 2 diabetes, status post CABG, presents with chest pain suggestive of IHD
before going through your SOAP format. Try and include only the pertinent findings and again summarise with your one liner. Then move onto your problem based list such as:
First problem is chest pain. We performed an EKG that showed ST segment elevation and did serial cardiac enzymes that showed a raised troponin. This was treated with PCI and symptomatic pain relief
- Work through your problems in order of priority. Do not forget chronic conditions such as control of HTN or Diabetes.
- Include a FENp at the end:
Fluids-Include any running IV fluids and balance Electrolytes-Note and abnormalities and corrections Nutrition-The type of diet the patient is on (e.g. low sodium, diabetic, soft food, liquids, etc) Prophylaxis- Including DVT, peptic ulcer etc
The attending will then sign off on your note using the above phraseology and adding his own comments.
- Orders are a curious thing that do not really exist in the UK. Your hospital may use a paper based system or an electronic system.
Essentially, you are free to write whatever you like in orders. Drug charts and the like do not exist. For example, if you are using a paper based system there will be stacks of order sheets on the floor. They may be ruled off in thirds, in them just write what you like such as:
'Run 0.9% Saline at 125ccs an hour' or 'Head CT stat' or 'ABG at 12PM'
and file them in the chart/hand them to the entry clerk. They will then input these and they will get magically done! Of course, they will need to be cosigned by a licensed physician.
- Orders are also written for admissions, discharges and transfers, stating things like the level of activity allowed, whether IV fluids are set to run etc. There are formats available in books such as Maxwell's (described below) to help you with this.
Again, this was a major difference to me. If you are on an inpatient service that accepts new patients, you will take call. The US follows the 'old style' system that used to exist in the UK. Therefore, depending on your service, you will be expected to 'take call'. This is where your team stays on call and admits new patients. This will either be every day using a 'drip system' where each intern will admit say two patients per day, or a one in three or four days system where you will admit every fourth day. Usually, this will last until 9 or 10pm whereupon you will signout your patients individually to the night team, giving them a brief runthrough of the history and anticipated overnight issues and then return the next morning.
- Dress codes can be relaxed for call and post call days, where you may be allowed to wear scrubs (ask your resident).
- As you can see, the call system dictates much of your life and will be referred to constantly. Sibling teams will be 'pre call, on call, post call' or 'off'.
- Most teams have a working week of 6 days per week. Once a month you should get a 'golden weekend' where you get Sat and Sun off.
- When on call, new admissions will be paged to the resident holding the team pager and then you will be allocated patients to go see, most of the time having to go directly to the Emergency Department to see and assess the patient there.
What do I need to bring?
Depending on your hospital, you may be provided with a white coat. If not, you will need to buy one. Make sure you do not do the major faux pas of buying a long white coat (knee length), ensure you buy a short white hip length coat as this is what medical students wear. You can pick this up in a bookstore or order online very reasonably.
- Clogs or trainers are very much welcome after a long day.
- Books: Buy a pocketbook for your speciality. I recommend the Washington Manual for Internal Medicine if you are doing a medicine rotation. Another essential book is Maxwell's pocket guide which gives you the format for writing out orders and gives you the common 'fish format' of writing out lab values (you will learn quick and come to love them!). It also handily gives you normal lab values which have some differences from the UK.