Worried about failing first rotation

[Medshpep2021]

Hi, I am a M3 who recently started my first rotation and am currently halfway through. During preclinicals, I was consistently above my class average (Dean said I was in the top 30% of my class on every preclinical exam) and I passed step 1 after grinding my ass off so I was super happy and enthusiastic to finally be in clinic. However, as preclinical test taking often does not equate with clinical performance, these past two weeks have been less than ideal.

First of all, from feedback from my preceptor so far (she knows that this is my first rotation), she says that I am consistenty performing below the level below that of a M3 not just in terms of professionalism (asking too many questions, not following schedules) but also in terms of clinical knowledge, reasoning, and etc. On the contrary, I have tried to be consistently punctual, humble, look for ways to improve myself, do 200+ Anki cards/10 - 12 Uworld questions a night after clinic, prepare for the next day, and respect/say hi to all the staff in her office. Even then, my introversion and lack of social skills have failed to work in my favor.

For example, there were scheduling changes for this week last weekend, I texted my preceptor several times on Saturday about my schedule. Due to fear of annoying her since she told me at the beginning of the clerkship when she first gave me her phone # to not text attendings more than a couple times a week since that could go the wrong way, I swore to myself not text her more. Come Monday, after my morning OR case, the attending surgeon who I was assigned to by my preceptor said that I could skip my 4 h long afternoon case to be in my preceptor's outpatient clinic (unrecognized scheduling conflict an hour into the surgery) and that it'd be pointless for me to leave the operation 1/4 the way in. Since my preceptor had said not to contact attendings unless necessary and I thought what the surgeon said was fine, I left the OR without texting for outpatient after the afternoon surgery began. Turns out my preceptor texts me on my way to outpatient to skip outpatient for surgery and I replied to her the surgeon was already in the OR and gave a clear sign to skip the 4 h long afternoon case for outpatient - my preceptor, clearly disappointed, says I should have texted her before doing so and largely ignores me in outpatient that afternoon. In addition, my preceptor has said that she has gotten multiple complaints from other attendings that she has assigned me with due to me appearing too eager and asking too many questions - even though I try to find the right time to ask questions such as not in the middle of clamping an artery or patient interview, I do admit I am more inquisitive than the average med student.

Still, I am introverted but my personality is not complacent - when I get pimped in the OR, there has been an instance or two where I found out that my preceptor was not fully correct and I Googled up information later to discuss with her and show my understanding/research, which only caused her pimp me harder and question my professionalism - something I highly regret doing now lol. Also, since my school only teaches anatomy in M1 and I barely reviewed anatomy for Step 1, I have also gotten multiple pimp questions wrong in the OR and was mocked at for my lack of knowledge for basic anatomy - for example, I missed a pimp question about the location of the bladder, and my preceptor proceeded to mock me and question on which side of the body the heart was. I always thought of myself as one to honor rotations, but based on what has happened these past 2 - 3 weeks and feedback from my preceptor that I am not performing at the level of an M3, I am worried I may actually fail my rotation, how should I improve?

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[DrStephenStrange]

Surgery was my worst rotation by far as well in 3rd year, and I even came close to failing it. It wasn’t my first rotation though, and I had very good feedback from prior rotations, so it was clear to my school that I just didn’t get along with this particular preceptor. I think the best thing you can do is to rectify whatever they think you’re not doing well, and try your best for the rest of the rotation to get that Pass and move on. Some surgeons are just very particular, impatient, and hard to please sometimes. I wouldn’t take any of that personally especially with this being your very first rotation.

 

[Prehealth1011]

The bright side is you’re done with surgery early. I strategically did my surgery/OB rotation at one on of our rural sites to avoid the attendings at our main site known to give bad evals, got in at 8 and left around 3-4, finished with glowing evals. M3 is a weird transition from preclinicals it’ll get better

 

[deleted1139416]

Although I agree that your attending is a lot tougher than most, I think the most mature and conducive thing to do is to take responsibility for where you went wrong and not make excuses for your behavior.

1) You were absolutely wrong about not letting your attending know about the schedule change. Even if you didn’t feel comfortable texting her, you should have at least emailed her or called her office front desk to ask about the schedule and them know you’ll be working there later in the day. Almost all attendants have an iPhone or an Apple Watch so they instantly get email notifications.

2) NEVER accuse an attending of being wrong. You aren’t Shawn in The Good Doctor. No one likes to be corrected by a medical student.

3) Don’t ask questions for the purposes of showing off. The problem is that you either end up asking inappropriate questions that you could have googled yourself, or you end up asking repetitive questions. This makes you look lazy, and ends up having the opposite effect. If you are worried about being too quiet which makes you seem uninterested, I would suggest doing it in a conversational manner. For example, once I saw a fistula in a guy with UC and I simply said “Huh, that’s weird since fistulas happen in Crohns, not UC”. And my attending said “Yes, very good, you’re right HipiMochi, but every once in a while it may happen in UC too”. This gives you the opportunity to show off that you are interested and have solid medical knowledge without risking being labeled the annoying med student asking a million questions.

4) On surgery rotations, you absolutely need to be aware of timing. Not sure about other places, but my surgeon would chew me out if I wasn’t READY and SCRUBBED in by the time he walked through the door. You should do the same. Sometimes the OR schedule is very disorganized and things change last minute, so I suggest having a go to person who is approachable (scrub tech, OR nurse, OR manager, etc) to keep you updated about what’s going on…. especially since these people find out about schedule changes before the attending.

 

[Medshpep2021]

@HipiMochi ok thanks for the feedback. I will be meeting with my attending next week again - she wants a follow up meeting to check in and see if things have changed and I will study over the weekend as well as try to not do any of those things again mentioned in my post. At this next meeting, should I try to bring up an example or two what I did again that I know have offended her to show that I acknowledge where I was wrong and apologize - which I haven’t exactly done at this week’s meeting or should I just nod at whatever she says?

 

[operaman]

Best thing you can do in the near term:

Take your top lip. Firmly press it against your bottom lip. Press as hard as you can and hold it there as long as possible. The longer you hold it, the higher your grade will be.

Reminds me of a subI we had one time who was pimped about what vessel the free flap was being sewn to. Student guessed lingual but attg told her it was actually the facial. She proceeds to ask the visiting scholar who was also there to pull up anatomy atlas pics of the external carotid and she goes back and forth between the field and the computer and finally comes to the attending again saying “actually I really think you’re sewing to the lingual.” The attending yells out “I think I know what the f—k I’m sewing to!”

That former ent sub I is now a cardiologist. And it was definitely the facial artery.

Your story reminds me of her which is why I shared it. And it may simply mean that you too are not destined to be a surgeon. Much of her issue as well as yours is simply not quite understanding and fitting in to the culture.

My biggest question after reading your post: where the heck are your residents?! You could really use some modeling of expected trainee behavior, especially more junior trainees. Much of how to behave is learned indirectly.

Other ideas for how you can improve:

1) see above lip pressing maneuver and practice it regularly.

2) don’t ever tell an attending they were wrong about a pimp question. The odds they’re right are 99.99% and if you’re not sure why even after looking it up, ask someone else. The way you’re asking is coming off like my now cardiology friend above. So if you have to know, direct that question elsewhere. Like if she had asked me after the case I could have shown her the 3D structure of the external carotid and relationships to key structures to show how we know that’s facial and how her way of counting branches and remembering her M1 mnemonic is maybe less accurate.

3) you need to prepare better for cases. Lots of books and websites out there now with lists of common pimp questions. Tons of videos so you can even watch other surgeons do all the key moves. Review the anatomy and make sure you can follow the videos and know what everything is the whole time. Review the patient’s chart and understand their history and why they’re having surgery. You should be able to give a full presentation for any patient you operate on, and we used to get kicked out of the OR if we couldn’t. Surgery is pretty boring if you don’t understand the operation and the goal; it’s a lot of fun if you do.

4) work on your presentations. Always from memory. Always structured well. I’ve written many detailed posts on how to do this so look at those. This is a big part of how people assess your knowledge level.

5) motto for surgery told to me by the intern on my first M3 rotation (also surgery btw): know more. Say less.

Know more. Say Less.

Tattoo that on your brain. Gather data and know a lot, but say only the key things that matter. Patients tell you all sorts of stuff that doesn’t matter. Keep all that to yourself and present only the key data. The attending doesn’t need to know the exact makeup of dinner, just that they tolerated a diet. If asked, you should know more detail, but otherwise keep the fact he had meatloaf to yourself.

 

[Medshpep2021]

@operaman - Thanks for the advice! I actually chose one of the only sites that has no residents because some M4s told me that our main hospital had some super toxic residents and to avoid that site at all costs so where I'm at is just medical students, nurses, PAs, and attendings.

 

[operaman]

@operaman - Thanks for the advice! I actually chose one of the only sites that has no residents because some M4s told me that our main hospital had some super toxic residents and to avoid that site at all costs so where I'm at is just medical students, nurses, PAs, and attendings.

Ok that makes sense, though especially tough for a first rotation. So much of what you learn M3 is indirect - like watching how residents present and conduct themselves in the OR. Attendings with each other and their staff can be much more casual and brief because they all know each other.

When my attending partner tells me about a patient and says “post op thyroid, no issues” I can be sure the all the possible issues were assessed and that everything is going smoothly. If an intern or pgy2 said that, I would have a LOT of follow up questions! Much of that dynamic is learned through immersion and observation.

In addition to the advice above, I would add to prepare like you’re a junior surgery resident. Know all the patients on service, pre round, draft notes if able. Prep for a case like you were going to perform the case yourself and the attending would just be out in the lounge available if you needed help (aka VA or County style). You’ll get more out of the cases and you’ll be a better assistant too.

But overall, just take it all down a notch. Know more and say less. If it’s only been a couple weeks then they will chalk it up to your first rotation and learning the ropes.

 

[EmperorK]

Hi, I am a M3 who recently started my first rotation and am currently halfway through. During preclinicals, I was consistently above my class average (Dean said I was in the top 30% of my class on every preclinical exam) and I passed step 1 after grinding my ass off so I was super happy and enthusiastic to finally be in clinic. However, as preclinical test taking often does not equate with clinical performance, these past two weeks have been less than ideal.

First of all, from feedback from my preceptor so far (she knows that this is my first rotation), she says that I am consistenty performing below the level below that of a M3 not just in terms of professionalism (asking too many questions, not following schedules) but also in terms of clinical knowledge, reasoning, and etc. On the contrary, I have tried to be consistently punctual, humble, look for ways to improve myself, do 200+ Anki cards/10 - 12 Uworld questions a night after clinic, prepare for the next day, and respect/say hi to all the staff in her office. Even then, my introversion and lack of social skills have failed to work in my favor.

For example, there were scheduling changes for this week last weekend, I texted my preceptor several times on Saturday about my schedule. Due to fear of annoying her since she told me at the beginning of the clerkship when she first gave me her phone # to not text attendings more than a couple times a week since that could go the wrong way, I swore to myself not text her more. Come Monday, after my morning OR case, the attending surgeon who I was assigned to by my preceptor said that I could skip my 4 h long afternoon case to be in my preceptor's outpatient clinic (unrecognized scheduling conflict an hour into the surgery) and that it'd be pointless for me to leave the operation 1/4 the way in. Since my preceptor had said not to contact attendings unless necessary and I thought what the surgeon said was fine, I left the OR without texting for outpatient after the afternoon surgery began. Turns out my preceptor texts me on my way to outpatient to skip outpatient for surgery and I replied to her the surgeon was already in the OR and gave a clear sign to skip the 4 h long afternoon case for outpatient - my preceptor, clearly disappointed, says I should have texted her before doing so and largely ignores me in outpatient that afternoon. In addition, my preceptor has said that she has gotten multiple complaints from other attendings that she has assigned me with due to me appearing too eager and asking too many questions - even though I try to find the right time to ask questions such as not in the middle of clamping an artery or patient interview, I do admit I am more inquisitive than the average med student.

Still, I am introverted but my personality is not complacent - when I get pimped in the OR, there has been an instance or two where I found out that my preceptor was not fully correct and I Googled up information later to discuss with her and show my understanding/research, which only caused her pimp me harder and question my professionalism - something I highly regret doing now lol. Also, since my school only teaches anatomy in M1 and I barely reviewed anatomy for Step 1, I have also gotten multiple pimp questions wrong in the OR and was mocked at for my lack of knowledge for basic anatomy - for example, I missed a pimp question about the location of the bladder, and my preceptor proceeded to mock me and question on which side of the body the heart was. I always thought of myself as one to honor rotations, but based on what has happened these past 2 - 3 weeks and feedback from my preceptor that I am not performing at the level of an M3, I am worried I may actually fail my rotation, how should I improve?

OP. Hear me out. You lack social skills, that's what you're describing here. It is why you're being told to talk less; you can't gauge how the interactions are supposed to go. So, at that point, you might as well not interact too much, so you'll get your pass. Additionally, when people describe themselves as introverts many times that is conflated with having lower-than-average social skills. You can be a social introvert FYI.
When people don't like you, and you have done things to antagonize them, they will perceive mistakes harshly. I bet you can tell they don't like you much, which is why you're anxious (e.g that whole scheduling thing you did there).

An effective way of fixing this is asking yourself, what is the other person trying to do? So, before you ask a question; is it relevant? Is there logic behind the question? E.g if someone asks you for a drug during an operation, do you ask what it does? OR do you ask what's half-life? how does it combine with the other drugs given etc. Can you joke with them? One thing that helped me is being able to rationally deduce the intention of the other person. Your preceptor is pimping you to teach you and gauge your interest/knowledge now. So, coming back later and doing that shows me you don't understand how the interaction is supposed to take place. There's no rational intention to you coming back besides just wanting to show that you understand it, which isn't the point of the pimping anyway. You could have said, "Hey man, I googled the question later on could I say what I think of it and you tell me if i got it right."

Can you now see why if you make all these mistakes in the soft department, you're going to get asked which side of the body the heart is?

 

[Esmolol]

Silly but… regarding timing for OR cases. Scrub in the very morning. Show up for case. Help with everything patient related. When patient is being prepped, wait for the team to show up. Tie the surgeon, tie the resident, go avaguard, gown and glove. Ready.

Also - if someone is upset with you - blame anesthesia…

 

[Smurfette]

Some good advice above.

Asking too many questions is not unprofessional; I am guessing it's the actual questions you are asking that is getting you into trouble. There are questions you'd expect an M3 to have, and there are questions that are above that level, as well as questions that are below that level or just not appropriate. If you are not knowing the location of the bladder and admit you aren't great at basic anatomy, I'm guessing your knowledge seems below the appropriate level or that you are asking things that are tangential and not as relevant. Remember, your classmates have taken the same classes as you, so if you are behind them somehow, you may not be retaining info as well or not reviewing the right information during this rotation. In surgery, you need to know 1. what is wrong (pathophys) 2. how to fix it 3. anatomy involved when fixing it 4. risks of fixing it, including anatomical ones as well as those related to medical comorbidities.

You are actually quite lucky that your preceptor has been giving you feedback and telling you that you are not performing at level, that you ask too many questions, etc. It is also helpful that multiple people evidently are giving her the same input, because that means it is not just a personality conflict with one particular surgeon but actually a problem. Have you asked your preceptor what you can do to improve? It is hard to hear you aren't performing as you should, but following that up with "what do you suggest I do differently to fix that?" may help demonstrate you care and give you some specific things to focus on going forward.

 

[BuildingMyOwnLuck]

A couple of points:

Come Monday, after my morning OR case, the attending surgeon who I was assigned to by my preceptor said that I could skip my 4 h long afternoon case to be in my preceptor's outpatient clinic (unrecognized scheduling conflict an hour into the surgery) and that it'd be pointless for me to leave the operation 1/4 the way in. Since my preceptor had said not to contact attendings unless necessary and I thought what the surgeon said was fine, I left the OR without texting for outpatient after the afternoon surgery began.

If assigned to do something and the plan changes, you should notify your preceptor, especially one like yours who sounds more strict. Most wouldn't care, but they clearly did.

In addition, my preceptor has said that she has gotten multiple complaints from other attendings that she has assigned me with due to me appearing too eager and asking too many questions - even though I try to find the right time to ask questions such as not in the middle of clamping an artery or patient interview, I do admit I am more inquisitive than the average med student.

Asking a question flowchart is basically: can you easily google this question? → if yes then don't ask. Also you should be able to see if they like answering questions. I've had attendings who did, and some who didn't, but it's better to err on less than more.

I found out that my preceptor was not fully correct and I Googled up information later to discuss with her and show my understanding/research

The only thing you're showing is that you think you as a M3 think you are smarter than an attending. Doesn't matter if it's right or wrong. In general, correcting superiors in any field is rarely a good move.

I have also gotten multiple pimp questions wrong in the OR

This is fine, every student had times where they blank out when being pimped. Try to read up on the case prior, but it's not as big of an issue as the other points.