How to succeed on rounds as a medical student
When I started my third year of medical school, I was absolutely terrified to present patients on rounds. Rounding is an age old medical tradition of discussing patients one by one in a group consisting of attending physicians, residents, and medical students. Like most medical students, I had heard the horror stories of pimping (for the never-been-pimped: this is where an attending or resident asks you questions in front of the entire team generally until you get a question wrong) and public humiliation. Let me be the first to tell you that pimping is almost never done with malicious intent (at least, in my own experience) and public humiliation on rounds is a thing of the past. Your one and only goal as a medical student on rounds should be to learn! Here are my top 10 tips for presenting on rounds.
Know your patients as best you can. Generally, as a medical student, you will have between 1-3 patients at a time. Thus, you’ll have ample time to review their charts and speak with them each day. You’ll be surprised how much you can learn about a patient by sitting down with them, even if it’s just for 5 extra minutes. However, it is okay not to know every detail. It is virtually impossible to know every single thing about each of your patients, and this is particularly true when you have more patients at a time.
Read about your patient’s medical conditions each day, even if just for 30 minutes to an hour. I personally recommend UpToDate and The New England Journal of Medicine (the absolute best medical journal with excellent review articles on many topics). Online MedEd is much more basic but a great place to start for background studying. Reading on your patients will help you come up with a plan each day for your patients.
Don’t be afraid to check in with your resident or intern before rounds to run your plan by them. A good resident or intern should be willing to talk the patient through with you. If they seem annoyed, that’s on them and don’t take it personally at all. Checking in with the residents also shows that you care about doing a good job and want to learn.
Don’t beat yourself up if you don’t know a medical concept that you are asked. 99.9% of the time, an attending or resident is quizzing you only to help you learn. Use these opportunities to get better and expand your knowledge base. If you don’t know something, look it up later. No one, and I mean no one, knows everything in medicine. This is why we have sub-specialists and numerous different fields in medicine. Go easy on yourself!
Rounds will vary by specialty. Surgery rounds are extremely short and to the point. After all, those surgeons are busy and have to get to the OR. Internal medicine rounds, on the other hand, can be quite long. During IM rounds, the patients are explored in more depth and you have time to discuss differential diagnoses and detailed management plans. Expect to speak a lot less during surgery rounds, but a lot more on medicine rounds.
The standard rounds presentation is in the SOAP format (Subjective, Objective, Assessment and Plan). Every rounds presentation should start with a one-liner, stating the patient’s name, age, and reason for hospitalization. The subjective portion of the presentation is next, and details what the patient tells you each day. For instance, if a patient has new abdominal pain, mention this in the subjective part. The objective component contains all of the lab values, imaging, culture results and any other data collected about the patient. Typically, you do not need to say every single lab value, but this depends on the attending’s preferences and will vary. You’ll catch on with this along the way. The assessment is your chance to summarize the patient succinctly and provide your opinion regarding diagnosis and the patient’s response to treatment. Finally, you will conclude with the plan. List each patient problem individually, and state what you are doing for each problem. Here is an example of a brief assessment & plan separated by individual problems:
Community acquired pneumonia
Assessment: Patient is recovering well and responding to IV antibiotics. The patient’s shortness of breath, cough, and chest pain have resolved. He has been afebrile for 24 hours now. He is no longer requiring supplemental oxygen.
Plan: Let’s discontinue the Vancomycin because his MRSA nares swab came back negative. Continue Cefepime today. If he looks okay tomorrow, we can transition to oral antibiotics, potentially Levofloxacin, and consider discharge.
Microcytic anemia
Assessment: The patient presented with a hemoglobin of 8.2 and a low MCV. I suspect likely iron deficiency anemia. The patient is 58, but has not had a colonoscopy. There is concern for colon cancer in a patient with iron deficiency.
Plan: Check serum iron, TIBC, transferrin saturation, and ferritin to confirm likely iron deficiency. Recommend outpatient colonoscopy. If hemoglobin drops below 7, we will transfuse him a unit of pack red blood cells.
You won’t be awesome at first. Don’t expect yourself to perform at the level of the residents. They have had more practice than you. Presenting takes a lot of repetition, but in time you’ll get better. As a third year medical student, I often times did not really know the exact plan the residents had for the day, and always just tried my best. I found that trying to come up with your own plan, rather than copying the resident, was a good way to impress the attending (even if you’re way off)!
If you think you found a unique physical exam finding on a patient, be sure to mention it on rounds. For instance, if the patient has a murmur, tell the team what you heard. This will be a good opportunity to confirm if you were right and learn something useful for the future.
Listen the entire time, even on patients that you’re not following. You can learn from just listening to what is going on with the other patients too.
Have fun! Ultimately, medical school is your chance to explore different specialties and decide the best fit for you. If you need a good laugh, check out this scene from Scrubs where they are rounding.