Basic Overview of Clerkships

Before we dive into each rotation, we first want you to understand what rotations look like and what resources you can use during each rotation in order to set yourself up for success with the shelf exams. The third year is very different compared to the first two years of medical school because you have to be in the hospital most of the time and also make time for yourself to study and figure out what content you need to study. It may seem overwhelming at first because there are so many resources available and such little time to learn on your own. Our goal is to provide you with the most high-yield information so that you feel ready to approach each rotation with a strategy in mind that will work best for you. But for now, let's get started with some of the basics. 

It's important to understand that every rotation is structured differently in terms of how it is graded, how long you are spending in the hospital, and what you are tasked with doing as a student. The goal here is for you to learn how to be flexible and adaptable to different situations and prepare yourself ahead of time so you know what your weeks will look like for the entirety of the rotation. If you prepare for each rotation by looking at the big picture overview then you will be less stressed. The goal is to try to spread out your studying day by day instead of cramming at the last minute which is very difficult because you still have to keep going to the hospital every day. 

We will touch upon specific study materials according to each rotation, so you can refer to the individual clerkship guides. Here, let’s briefly discuss what grading and expectations look like during rotations as a whole. Grading is generally based on two main components: your shelf exam and your clinical performance. The shelf exam is an NBME exam of 110 questions that you take on the last day of each rotation. We’ll discuss how to prepare for this exam in each clerkship guide. 

The clinical performance is based on MedHub evaluations submitted by ~all of the residents and physicians that you work with. The MedHub evaluation criteria for each rotation can be found on Bright Space. Don’t stress too much about the nitty-gritty details of the evaluation, just try to do your best and a good clinical evaluation will follow. The remaining components of your grades may include extra work like submitting a CEX form, writing up an HPI, or other little tasks. Each rotation will have its own additional criteria which we will discuss later. The breakdown of grading criteria and how much each component weighs also differs based on the rotation. For example, some rotations may weight clinical evaluations at 75% while the shelf exam is 25% and others may distribute that differently. Some rotations like Psychiatry have notoriously harsher grading on the shelf exam compared to others. 

The gist is that you should try to do your best as a whole and let the evaluations and grading fall into place as they should. Don’t over-stress. At the end of the day if you pass, high pass, or honor a rotation it will not prevent you from being a doctor or matching into residency. Of course, you want to try to honor the rotation of a specialty you are considering applying into, but if you want to go into OB/GYN residency, and happen to pass or high pass your neurology rotation, don’t freak out! You’ll be a great OB/GYN someday. 

Remember that your clinical evaluations from faculty are supposed to be objective according to the rubric but they can be subjective because we are all humans and perceive others through a certain lens. With that in mind, if you find that you are being mistreated or targeted in a negative way by faculty, do not hesitate to reach out to your clerkship director immediately, or someone disconnected from the clerkship like one of the deans if that makes you more comfortable. It is better that you bring this issue to their attention earlier rather than after the rotation. 

• Here's a  clarification on how our faculty feedback is used and how we are protected from consequences of "negative" medhub evals:

• If you were to complete an evaluation to provide preceptor feedback, it would be grouped together with feedback from this entire academic year or in some cases, over a 12-month period. In my experience, some departments use the reports differently, but in general it’s for an annual/bi-annual review.

• If you have concerns regarding student anonymity, please know there are controls in place.  Faculty are not provided evaluation reports at the end of each rotation block and there are a minimum number of evaluations required for a report to be generated.  All student identifiers are also masked for confidentiality purposes.

This is a tough portion to touch on because expectations can vary significantly from rotation to rotation, from different sites, and between the different faculty you will be working with. Some rotations and sites may expect you to only observe and not do much, while others may expect you to see patients on your own and write notes and do much more. Your job is to get a quick understanding of what the expectations are early on. To do that, speak with your preceptors early and ask what they want you to do and how they want you to do it. It’s okay not to know what you are supposed to do or how to do it when you start off. So just ask and then do as they show you. Most often, students get dinged on clinical evaluations because the expectations of faculty weren’t met because they were never communicated clearly. So be sure to communicate with your team. 

You really learn everything you need to know while on rotations. Remember that you will be learning medical content, but also other skills that include using a pager, how to write notes and navigate Epic, how to effectively present patients on rounds, and other subtleties as you go along. Your preceptors don’t expect you to know everything about medicine and treatment plans. That will improve with time and exposure (and that’s really what residency training is for). What you should be able to get a good grip on are the other “soft skills” like working with a team, seeing patients, writing good notes, helping prep the OR, and managing your way around the hospital. 

Here are some of the general DOs:

• Do email your preceptors ahead of time to ask about when/where to show up.

• Do ask them if they expect you to prepare anything before day one.

• If you need to miss a day for a conference, research, or personal reasons make sure you email them and remind them in person as well (in advance).

• Show up with enthusiasm and be engaged!

• Ask questions and actively participate during the day.

  • Be aware of when it is a good time to ask a question and when your residents are too busy in the moment.

• Try your best to help your team as much as you can with whatever you can.

  • This can include writing notes, calling consults, calling family members, and whatever else they may ask you.

Here are some DONT’S: 

• Don’t be late! 

• Don’t fall asleep when you are with your team (believe it or not this happens…)

• Don’t do Anki or UWORLD during patient care, rounds, or other moments when you are supposed to engage with your team.

  • You can totally study during the day during slow work but make sure you are aware when is appropriate and when it is not.

• Don’t be rude to faculty, staff, patients, or your classmates.

  • Faculty can easily point out when you aren’t being a good classmate and taking over the conversation, so be considerate if you are working with another student. You don’t need to put someone down in order to look good in front of preceptors. 

• Don’t miss attending the extra requirements like didactics, conferences, clerkship meetings, or other things that are part of the clerkship. 

• It is usually a good idea to split up studying on an excel spreadsheet detailing how many UWorld questions and OnlineMedEd videos (or other resources) you want to get done in a day for each clerkship. It’s good having the questions and videos done a week before the shelf so you can spend that week going over topics you aren't super comfortable with and going over your incorrects in UWorld. For example, if a clerkship was 6 weeks long, you could budget 5 weeks x 7 days/week = 35 days and then divide the number of questions and videos by this for the daily amount. This really helps keep you on track with studying and preventing cramming.

• We HIGHLY recommend having one night a week where you do not do anything but relax, participate in your hobbies, talk to family/significant others/friends (if you can, this is harder for some clerkships).

• It is recommended to take a practice NBME shelf around halfway through the clerkship to gauge where you are in studying and topics that you struggle with. You should also usually take a practice shelf the weekend before the shelf.

• To learn more about studying, resources, and time management you can later read the Basics of Studying on Rotations.

• Here is what a sample study schedule might look like for a rotation.

• Here is some general advice. We will delve into deeper aspects within each clerkship guide, but this should give you a good overview.

• Write a note? (relevant information for all rotations)

  • Templates are the backbone of notes in Epic. Steal some from your residents or fellow med students for each clerkship. Go to "Smart Phrase Manager," search the person you want the template from in the search box, find the note in the list, double click, click create copy at the bottom right hand of the screen, rename it (I usually put my initials and a descriptor), click accept. Now when you open a new note, you can put a “.” followed by the name of the template and hit enter to open the template. P.S. you can definitely steal templates from anyone (other students, attendings, residents, etc.)

  • In inpatient, “pend” means save but not sign (will show as incomplete); “sign” means sign (but you can addend before your attending cosigns if something big changes or you notice a glaring mistake). 

  • In outpatient, depending on your attending’s preference you can either “sign when signing note” which allows them to edit your note before they sign the encounter, or “sign when saving note” which signs your note after it is saved and sends to your attending to cosign (only choose this option when you are completely sure you are done with the note!).

• Pre-round? (more specific to internal medicine)

  • On inpatient service, you will be assigned 1-2 patients in the beginning of the year and up to 3-4 at the end to follow. If they are new patients from overnight, get their full history from whoever admitted them during sign out/from the H&P in the chart. 

  • Print yourself a handoff for your patients (make a separate list with your patients in it, then at the top left corner you will see “print handoff”). This sheet has a ton of info on it, including To-Dos and is so helpful to round with.

  • The Summary tab will be your friend, believe me. I would set up the sub-tabs to show VS (vital signs), Labs, Medications, Micro, and Radiology at the minimum. It’s like a one stop shop for all of the info you need for pre-rounding.

  • Here’s the work flow I use (tailor to your own preference): get "sign out" from the night team on updates overnight, go to the summary tab and get vital signs, labs (just report the most recent), micro results, and radiology from the past 24 hours, along with PRN medications that the patient needed throughout the night (i.e. antihypertensives? Pressors? Pain meds? Electrolytes?), go to chart review and look at recent notes (consult notes, nursing notes are especially helpful for overnight events), go see your patient and ask how their night went/concerns, do a brief tailored physical exam, review your assessment and the plan (helpful to ask the resident who is co-managing to review this with you), and then present on rounds!

  • I like to get a progress note started on the patient prior to rounds because it makes my life easier (and then you can pend).

• Present a patient? (more specific to internal medicine & inpatient setting) 

  • For the inpatient setting, you should follow the SOAP format and it’s the most universal for attendings to request this. 

  • Start with a one-liner that reminds the attending who this patient is. 

    • 1. An example for medicine: this is Mrs. Smith our lovely 81 year old female with a medical history significant for hypertension and CAD s/p two stents who was admitted on 5/16 for acute onset shortness of breath and worsening orthopnea. 

      2. For surgery: this is Mrs. Smith our lovely 81 year old female with a past medical history significant for atrial fibrillation on Eliquis anticoagulation who is post op day #1 from an endoscopic endonasal resection of a pituitary adenoma.  

  • Subjective: How did the patient’s night go? Any events/issues (including whack vitals or labs that led to interventions)? How are they this morning? Any significant use of PRN meds?

  • Objective: Vitals, physical exam, and labs/micro/radiology that are recent and haven’t been discussed yet

  • Assessment: Overall, is this patient getting better? Worse? New problem? Change in your differential of what’s going on?

  • Plan: Include orders that are pending and new orders that should be submitted!

• Page someone?

  • If you can at all, text paging is >>> than paging on the phone. It gives the person you’re paging context and the ability to return at their luxury. You can text page by searching the person’s name in the directory on the mayo intraweb page, click their pager number, and enter your text.

  • Do not tone page people unless it’s an emergency. It’s generally poor form.

  • On a landline phone:

    • 127 

    • Last four digits of the pager you are paging (i.e. 5446)

    • Your pager number (i.e. 13235)

    • # sign

  • If a pager number starts with “2”, it’s a connected with a phone, so you can directly call it (enter the number directly into a landline – i.e. 25446). 

• Answer a page?

  • If someone pages you back after you leave your number through the landline option above, it will be a tone page (long beeps sounding from your pager). Go to a landline, hit #1yournumber (i.e. #13235). You’ll hear a faint click and then you should say who you are and what service you’re on (i.e. "this is Nicole with neurology"). If you wait for someone to start talking from the other end, it will be super awkward.

  • If someone pages you a number, just type that as is into a landline and tell whoever answers that you are answering a page. 

• Call a consult? (relevant to inpatient setting) 

  • For your first one, you should ideally have your intern or resident around to help. You want to have a good grasp on your patient, specifically their history and why you are calling the consult (what clinical question do you need help with/want answered). 

  • Typically, your resident will put in an order for a consult from a service (or you can put in the order and save it for your resident to co-sign if you feel comfortable).

  • You should then page the service to talk to whoever is on call for consults. 

  • In the Mayo Dock, under the Patient Care folder in the Global option, find “Web on Call” (the so-called Red Phone; save this to your personal dock) and click. Find the service in the drop down box. This will show you who is on call for that service and the pager number. If the list shows both a resident/fellow and an attending, page the resident/fellow first.

  • Page the service number (use what’s outlined above using the landline option, unless otherwise informed).

  • When they page you back, say that you are with "so and so service" paging about a consult. Say the patient’s name and room number and ask if they need the MRN number (usually they don’t because it will be on their consult list from the order you already placed). Then give a one liner about the patient’s admission history and then go into why you are consulting the service (relevant history, physical exam, labs, imaging, etc.).

• Do my best on a clerkship?

  • Honestly, 90% of clerkships are being present, ready, and eager to learn. Try to get out of your comfort zone and absorb as much clinical information and hospital/clinic logistics as possible. See what you can learn that will make your resident's life a little easier (because some day you are going to have to do those things as a resident too) – try calling family, updating the patient and family in the afternoon, following up on test results, calling consults, taking on consults or admits, etc. 

  • If you don’t know how to do something, ask someone to teach you! People are super friendly and will usually take the time to teach because then you can function a little more independently in the future. Don’t be afraid of asking a resident/fellow to watch them do something first before you attempt on your own.

  • Writing a hospital course for a patient is the easiest way to have your interns be super impressed by you. It’s so helpful. Seriously. Outside of Mayo, doing anything like updating lists or other organizational things is also super appreciated.

  • Clerkships are a lot, and you will get stressed and overwhelmed. Everyone wants to help you succeed, including the residents and attendings you work with, your fellow classmates, and your clerkship directors. Reach out for help if you need it! 

• Don’t forget about…

  • Senior Sage Assignments! 

  • EBM Assignments!

We are excited to see you guys in the hospital!! Just remember: you are learning. Give yourself some grace and patience.

Sending an intro/thank you email is a great way to be practical (i.e. introduce yourself and ask where to meet your team) and to show that you're motivated and interested in doing well. The reason why I emphasize the power of a good email is because evals are important. Use this email template to remind your preceptors that you want your efforts reflected in your evaluation score. 

To Note: Sending an email is optional. If it feels inauthentic to your experience or if you have a million different preceptors within one week and sending an email to every single one seems like too much, don't feel obliged! Emails are not expected, but can be appreciated in the right situation. 

Intro email template: 

Good morning, Dr. [***]:

Hope you're doing well.

My name is [name]. I’m an M3 at MCASOM AZ, and I’ll be working with you and your team next week as part of my [***] clerkship.

I'm originally from [***] where I went to the University of [***]  for undergrad and majored in [***]. I also [any relevant professional experience e.g. worked as an MA at a neurology clinic if this is your neuro rotation].

I have professional interests in [***]. I aim to Honor this rotation, so I will do my best to ensure my performance reflects my goals and dedication.

My goals for the upcoming week are to... [e.g. participate as much as possible in the OR and to improve my presentation skills]. I'd appreciate any feedback you have for me throughout our time working together. 

Thank you for your time. Looking forward to Monday.

[name]

Thank you email template: 

Dr. [***],

Thank you for letting me spend the last week with you and your team. [you can add details about a special case or whatever]. 

Also, when you get a chance, could you please fill out a Medhub evaluation for me? My goal is to Honor this rotation, and I hope my efforts are reflected in my scores. Thank you in advance! 

Have a great week. Hope to see you around the hospital again soon. 

[name]