For all you third and fourth years out there, are there any online resources (or can you just provide some information) on how clerkships are broken down (particularly medicine and surgery)? In what ways does one get exposure to some of the specialities during these periods?.
I'm not sure where you can find online resources, but I can break it down for you pretty well:
3rd year is a total of 48 weeks of clerkships, broken up as follows:
- Medicine. (Included: General internal medicine and some medical subspecialties, radiology, dermatology, hospice/palliative care)
You will spend a total of 12 weeks on medicine, broken down into 3 four-week sessions. 2 of those sessions will be inpatient, and can be done at University, the VA, Mercy, Union Memorial, or 1 or 2 other sites that I can't remember off the top of my head. On your inpatient weeks, you will be q4 (meaning you take call with your team every 4th night), which includes weekends, averaging out to one day off per week. You will not stay overnight - instead, you will stay typically until 9-11pm, or until you have "capped" at your personal max # of patients, and have finished helping out the housestaff for the day. On inpatient medicine, you will carry anywhere from 1-4 patients - you will follow them, do the H&P, present them, do their workups and scutwork, etc., with input from the resident and attending. I typically got in around 6pm when I had 1-2 patients, or 5am when I had 3-4 patients. There are didactic sessions pretty much every day (morning report in the AM, noon conference), and then radiology readings once a week. Some sites are exempt from some of these "extras," since they are held at University/the VA...but most of these away sites have their own morning report and noon lectures that you will go to instead. Dress is business, unless you are on call (scrubs are OK in that case).
You will spend 1 four-week session on outpatient medicine, which is a blend of clinic at an assigned site (e.g. University, Union Memorial, St. Agnes, Franklin Square), along with hospice/palliative care (4 days out of the 4 weeks, with a take-home test and writing assignment), and dermatology (lectures once or twice a week with a "test" at the end). As with inpatient, you will still have some didactic sessions. There is no call on outpatient months, and your weekends are your own. The clinics that you will attend in the AM and PM will vary, and just about any subspecialty is possible as an experience. For example, we had general medicine, renal, pulm, oncology, and endocrine clinics where I rotated. However, you won't have a whole lot of time in clinic because you are constantly running to other sites (derm lecture, hospice, etc.), so you might not get too much experience in these subspecialties.
You may be assigned the 4-week sessions in any order, so some people have outpatient first, some have it in the middle, and some (like I did) have it last. Regardless, at the end of the session, on the very last Friday, you will take your medicine shelf exam.
- Surgery. (Included: General surgery and/or surgical subspecialties, ICU, anesthesia, wound care, trauma and EM)
You will spend a total of 12 weeks on various surgical services. You will have two 3-week blocks. Everyone has 3 weeks of Shock-Trauma service (I'm on this right now) which is a blend of emergency medicine and Trauma/Emergent surgery. On this 3-week block, you will take q3 call with your team (including weekends), and stay overnight - you are usually awake for the majority of the night admitting people, helping out with traumas, in the OR with emergent cases, etc. It's a lot of fun and they typically let you do a lot. During the shock trauma rotation, you will also spend 2 days on one of the ICU teams (there are 3 ICUs in STC), learning what a surgical ICU is like.
The other 3-week block will be spent either on a general surgery service (Univ, VA, or Mercy), on the transplant service, surg onc, or peds surg. Call, hours, and autonomy/experiences will vary widely depending on which service you are on. I was at Mercy, where I spent 2 weeks on their general surgery service and 1 on vascular, with 2 other students. We showed up anywhere between 5-6am, scrubbed in every day (often to multiple surgeries), and were actually encouraged to participate - for example, my first day in the OR, I got to be first assist on a complicated case (a bit of a fluke, but still...), and we usually left around 5-6pm, although there were a few nights that cases went as late as 9pm. We each took 4 overnight calls which were variable in terms of how busy they were - usually we slept from 1-2am until 5. Other students on different services worked better/worse hours and took more/less/no call, and some of them were only able to observe in the OR, and not really participate (transplant comes to mind).
There is one 2-week block where you are assigned to a subspecialty service (cardiac, thoracic, vascular, minimally invasive, or urologic surgery). I can't speak to these, as I haven't done mine yet. I don't see them being much different from the 3-week blocks.
I'm sure you can probably "request" one site/service or another, but most of us were randomly assigned to each of the 3-week and 2-week blocks. Dress is scrubs for all of these blocks.
The last 4 weeks of the surgery rotation are divided up into 1-week blocks. Everyone has to do 1 week of orthopedics; the other 3 you can choose (to some extent - they try to accomodate everyone, but can't always) between ENT (+ 1 half-day of ophtho), urology, plastics, wound care, anesthesia, and neurosurgery. I'm not sure what the call requirements for these 1-weekers are yet, but I know that for some (ortho comes to mind) you will have clinic days where you need to dress nicely (not in scrubs).
There are 2pm lectures and sporadic small groups that you are expected to go to while on surgery, unless you are at an away site (like Mercy). The final Friday of your surgery rotation, you will take the shelf exam.
- Family Medicine. For 4 weeks, you will be assigned to either the campus clinic (about 2/3 of the group of students), or to an off-campus clinic just about anywhere inside of a 1-hour drive radius. It is basically 9-5 clinic, with no weekends or call. On Fridays, you will have lecture for the entire day (9-), although you rarely use all of that time, it's usually more like 9-3, but don't quote me), and those who are at the campus clinic will have morning report with the family med residents. Dress is business. I was one of the off-campus people (I requested it, actually). There is a 1- or 2-day requirement spent on the family med inpatient service (UMMS family med has admitting priveliges for their pts and you will follow them just as you would on internal medicine) - you can do more, if you choose, and take overnight call with them if you really want. This rotation is a good way to gauge whether or not you think you might be interested in primary care. On the last Friday, you will take an "in-house" shelf exam written by the FM faculty, which is computerized.
- Neurology. You will spend 4 weeks on one of 3 services: University wards, Univ consults, or VA consults. University wards is their own inpatient service - just like on medicine, they have their own patients for which they are the primary team. This also means that they have to come in earlier, pre-round/round on all of their patients, etc. The consulting teams are similar in that they don't have their "own" patients, but they act as consultants to the primary (typically either medicine or surgery) team when the pt is suspected to have a neurological issue. You will be doing lots of physical exam, learning how to manage stroke, etc. For the VA consult team, you will have clinic 3 times a week in the afternoons, where you will typically see 2 patients. You will be in charge of writing their notes and putting in their orders. It is a chance to see some really random stuff (I saw a guy with inclusion body myositis...) and hone your exam skills. There are different clinics on different dates for patients to follow-up in, e.g. stroke clinic, neuromuscular clinic, seizure clinic, etc.
You are required to take 2 call nights while on neuro, regardless of what service you are on. Univ wards and consults work on Saturdays, I believe. VA consults are off on weekends. Dress is business for all services and clinics.
You will have lecture around noon evert Tue-Thur. The last friday of the clerkship, you will take an "in-house" shelf exam written by the neuro faculty. This year it was a packet of short-answer questions and one really long essay question.
- Psychiatry. You will spend 4 weeks on a psychiatric service, taking care of, typically, very sick psych patients. You may be assigned to one of the psych wards at University (general psych or geriatric psych), the Walter P. Carter Center, Spring Grove Hospital Center, or split your time with 2 weeks on a psych consult service, and the other 2 on the substance abuse service. The patient populations at both WPCC and SGHC are mostly comprised of people suffering from schizophrenia, although many have more than one psychiatric diagnosis. You will learn how to interview and write up a psych patient, no matter where you are assigned. The hours are typically 8 or 9 to 4 or 5, and you will often interact with your patients in the role of group facilitator or activity leader.
There is one overnight call (which you will do at University wards, no matter where you are assigned), and one weekend day at the PES - psych emergency service, which is basically an ED for psych emergencies, like suicide attempts, manic patients, etc. Dress is business for all services. The final Friday of the rotation, you will take the psych shelf exam.
I will let my classmates talk about OB/gyn and pediatrics, as I have yet to do either. I do know that each are 6 weeks, and OB/gyn is broken into 2-week blocks of outpatient, gyn/gyn-surg, and L&D, and that peds is broken up into 3 weeks each of inpatient and outpatient.
Second, I have heard of students during the summer between their first and second years completing their first clerkship (particularly in pysch). Does this allow one to "bump up" their electives to their third year (instead of fourth year)?
This is only true if you are accepted to and participate in the CAPP program. I don't know of any other rotation that you can get credit for, except for psych. The CAPP students do most of their training in psych during 1st year, and then spend the summer working on a psych unit/project, which counts as their junior psych clerkship. However, they still have to do 4 weeks of psych as part of their junior year - but they can take more advanced electives (e.g. schizophrenia clerkship, child psych, substance abuse, etc). I don't think anything else counts, though. There are some courses, like medical spanish and a few others, that will count as senior elective credit, but that's it.
Lack of elective time in the 3rd year is the most major gripe that I have with UMD. I am highly interested in 2 specialties that you get very little exposure to in the 3rd year, and to make matters worse, neither is offered as a sub-internship during 4th year, so I'm probably going to have to burn all 4 of my senior electives up front.
Third, I continually hear about patient "responsibility" during clerkships which is both quite exciting and intimidating. From a day-to-day dynamic, how does patient management "work"? In other words, are you left on your own to figure out patient care through your own knowledge as well as reading clinical texts? Or does a mentor guide you along in determining the course of treatment? I am quite curious what to expect during third year. (The first day of service must be quite scary...)
You'll get the hang of it. It's not like they drop you in the middle of 6S on your first day of shock trauma and say "good luck." Learning how to manage patients is what 3rd year is about! Also, it varies substantially from rotation to rotation, from service to service, and from hospital to hospital. On some rotations/sites, you will have someone holding your hand every step of the way. At other places, you may be left on your own quite a bit to figure things out. Since starting 3rd year more than 6 months ago, I've felt "uncomfortable" with my expected level of responsibility only a handful of times, and I can pinpoint those sentiments to particular factors that were going on at the time. Those "factors" went directly into my evals, or, in a couple of cases, directly to the clerkship directors - who, I must say, have been extremely approachable and immediately responded with concern. You should not constantly feel like you are out of your league (although once in a while it's to be expected), and you should not
ever feel like you are being forced into a position where your or a patient's life or well-being is in danger. You are there to learn, not to make the final medical decisions. It's OK to be wrong as a student. If you're not getting enough guidance, definitely speak up about it. Clerkship directors want to hear these kinds of things, because they actually care about improving the experience.
Fourth, I know that there are several options between first and second year: research, some type of pre-second year coursework, clerkship (as I alluded to above), and vacation. Can someone describe the advantages and disadvantages of these options?
I think the smartest thing to do is engage in some meaningful research, and take some time to have a vacation. I think you have something like 10-11 weeks. Use them wisely. As for what to research...they sky's the limit. What are you intersted in? What specialty might you want to do? Have you done research before, and can you use this summer to extend the project? Can you publish? Can you continue this research into 2nd year and beyond? (I'm asking rhetorically...not looking for a specific answer, just giving you food for thought.)
Fifth (sorry for SO MANY questions), there is alot of talk between schools about grading vs. P/F. Do you feel that there is more stress in your lives due to the grading system? Dr. Foxwell indicated that it was the students who decided to keep the grading system in place as it is, in order to help differentiate students later on. However, I thought it was really the clinical rotations that matter more for residencies. If that is the case, why would grades matter in the first place?
No, the grading system isn't a big deal. Usually, people only stress over their grades for the first few exams. After that, it only causes stress to those who feel the need to talk about and compare their grades with other people, which most students don't. As a matter of fact, we have a kind of unspoken rule amongst our class that we don't talk about grades. Yeah, I'm sure it's nice to get A's, but most people get B's and some get C's, and we all pass, and after first and second year are done, we pretty much all start over from baseline, anyway. It's important to know your shi%, but that's about it. For most specialties, clinical grades do matter more (especially your rotation in that particular specialty), as do letters from people in that department, and your board scores.
Hope that answers some of your questions!
love
