So You Want To Rock Your Rotation?

 This post by Dr. Margaret Goodrich is a one stop guide to excelling on your EM Rotation. In this very weird year, impacted by the COVID pandemic, you may only get to do one EM rotation. Make it count.

Professionalism

While some of this may seem redundant to what you’ve been told in the past, sometimes it just needs to be
said again. While your clinical knowledge is part of your evaluation, another major part is HOW you do the job
and your interactions with others. 

Be punctual

The old adage of “if you’re on time, you’re late”. This applies to shifts, conferences, SIM, workshops, meetings… basically everything. Plan for travel time, figuring out where you’re supposed to be, parking, etc.

Dress for success

Thankfully in the ER that means clean scrubs and close-toed shoes. Depending on the rotation, they may have a dress code for conference/didactic sessions. Whatever it is, respect it. It is worth bringing a business casual outfit (or two) and even a suit (some will interview you while you’re there).

Attitude

Come in to work ready to work! This is a job that demands you be “on” the entire shift. Be ready for that.  Show that you are excited to be on your rotation, in the department and working alongside potentially future colleagues. Your attitude will affect those around you. Think about what kind of influence you want to be.

Take Initiative

This shows that you want to be there and want to learn in the ER. Each program is different with how they get you involved in patient care (will have you just sign up and see them, will direct you towards patients), get a sense of this then find ways to be proactive about it. However, even if you know how to do a procedure, DO NOT just start doing it without talking to your resident/attending. Touch base with them, let them know you’re willing to do it and ask how they would like for you to proceed.

Be Inquisitive

This job is ALWAYS changing and there is always something to learn, especially early on. When you’re thinking about a patient’s care, ask “what else?”

• What else should be on my differential?
• What else could be an intervention?
• What else could be part of this work up?

Find something that was interesting on each shift, then go home and learn more about it. A chief complaint,
an intervention, a procedure, etc.

Respect

Be courteous to those you interact with (residents, attendings, program coordinators, nurses, techs,
secretaries, cleaning staff, patients, families… LITERALLY EVERYONE). Believe me, it will be noticed
if you are rude to someone. The value of “please” and “thank you” cannot be understated

Honesty

Be open and honest with your senior resident/attending. If you haven’t done something before, THAT IS FINE! It would be unrealistic to expect that as a medical student you are proficient at many EM skills. That’s the whole point of residency. It is UNACCEPTABLE to lie to your senior/attending about your skill level. If you haven’t done it, just say so. Then demonstrate that you are eager to learn about it (YouTube is great to find a quick video, or check out this website: https://www.emra.org/students/advising-resources/skill-demonstration-videos-and-topics-pertaining-to-em/ ) and be prepared to try!

Effective Communication

This is going to be paramount throughout your career. Now is a great time to continue working on it!

Who’s who?

Make an effort to learn the names of the people you work with. It will take time, but it makes communication
more personal, easier and more direct.

Closed loop communication

Make sure the person you’re talking to actually knows you’re talking to them (using names is really helpful
here), they hear what you want, and verbalize that they understand what you want them to do.

Example: “Joe, please get an EKG on Mr. Smith.” “Ok Doctor, I will get an EKG on Mr. Smith.”

This ensures that the other person is aware an action needs to get done. It also provides them with an opportunity to tell you that it is beyond their scope of practice or that they are not able to perform that now. Which means that you can find someone else to get it done and not wonder why it hasn’t been done after an hour.

This is not only important for general patient care, but imperative for resuscitations/trauma/high acuity
patients when things can become chaotic quickly or the patient requires a number of interventions
simultaneously.

Respect

We already mentioned it, but it’s worth mentioning again.

Feedback

How to make the most out of what your preceptors are telling you!

Blind spots

We all have them. Feedback from your preceptors is a great way to discover areas that you need work on
that you weren’t aware of.  Make note of these somewhere (on your phone, a physical notebook, stone tablet, whatever), then evaluate how you can work on them.

Setting up your shift for feedback

Some preceptors are more conscientious about giving feedback than others. To help you get feedback, decide something specific that you want to work on before your shift. Once you arrive, tell your preceptor what you would like to work on and ask them for feedback on it at the end. This does two things:

1. It makes you be cognizant of a specific goal for the day rather than “get better”
2. It sets up your preceptor to know that you are actively looking for feedback and that they should be keeping in mind your goal for the day. It helps them to give more direct feedback rather than “nice job”

But what if I don’t like the feedback?

Inevitably, you’re going to get feedback you don’t like/rubs you the wrong way at some point. We’ve all
been there. When this happens, our natural response is to get defensive. Take a minute, think about
why you’re getting that feedback. Is there something that you didn’t realize before (blind spot)?
What can you do to fix it?

What do I actually do with the feedback?

Attempt to make an active change. There is no point in getting feedback if you don’t make an adjustment.
If it is in the middle of shift and it’s something that could be done on your next patient encounter, try to
do it then. If it’s the end of shift, consider it as your goal for your next shift or for the topic that you’re going to learn
about before next shift.

During Shift

The art of actually doing things.

Workflow

Starting to develop good habits now can help you as you start residency. Below is a general outline for
ED workflow:

STEP 1: Pick up a patient. This will vary by institution. Touch base with the senior resident/attending to see if there is anyone to see and ask them how they would like for you to see new patients throughout the day. Wait for them to tell you? Pick up new patients on the board? Ask them each time a new patient is available?

STEP 2: QUICK chart evaluation, review documented vital signs (if available). Do NOT wait 15 minutes to go see the patient. If you’re picking them up you should be ready to see them shortly.

STEP 3: Actually see the patient, do your HPI and exam. *IF AT ANY POINT you have concerns about vital signs, mental status, a specific exam finding that would require EMERGENT attention, quickly excuse yourself from the room and find your preceptor.* You will not be faulted for grabbing preceptors sooner rather than later if you’re concerned about the patient.

STEP 4: Develop your differential and management plan. There are a number of different mnemonics but one that I like is SPIT:

• Serious - all the big bad terrible things that as an ER doc you need to at least consider
• Probable - while you have to consider all the terrible things, what do you actually think is going on
• Interesting - what’s the zebra diagnosis to consider?
• Testing/treatment - what labs, imaging, medications, fluids, etc would you want to help you evaluate and treat the patient?

Your preceptors will usually want the serious differential items FIRST, but also include the other items on your differential as well.  Know that your management plans are not going to be perfect. That’s part of learning. You will learn more by developing a plan and presenting it then discussing with your preceptor why they agree or disagree. If you simply wait for them to develop the plan for you, you won’t learn as much.

STEP 5: Follow up on testing. It’s always great if you know the results before the preceptor. Think about what the results mean (even if they are normal/reassuring), and what the next steps would be.

STEP 6: Reassess the patient. If the patient has received an intervention, how are they doing after that? Is there something else you want to do as an additional intervention?

STEP 7: Determine what you think the disposition is. This is helpful to think about after your first encounter with the patient because it helps you to get a sense of where the visit is headed. Obviously things change, but it will help to try and get a sense of: sick or not sick? Going home or getting admitted? Is there a safety reason why they shouldn't be discharged (like social work or case management needs)?

Procedures

There will likely be some opportunity to do procedures during your rotation. Again, this will depend on the institution and your preceptors. Be eager and willing, but as stated above DO NOT LIE ABOUT YOUR ABILITIES/EXPERIENCE. If you haven’t done it before, inform your preceptor, preferably not in front of the patient.

Find a resource to help you learn how to do procedures that you haven’t done before, like this website: https://www.emra.org/students/advising-resources/skill-demonstration-videos-and-topics-pertaining-to-em/

Know the indications, contraindications and technique of the procedure. Ask for help if you need it.

Notes

This is incredibly institution dependent. Some will allow you to write notes, others will not. If you are allowed to write notes, certainly do your best with it. You should get more instruction from the institution on what your specific duties are

Daily goal

Determine what you want to work on for the day. It’s more helpful if it’s specific, rather than “get better”. Inform your preceptor of what you’re working on for the day.

Presentations

This is something you will be doing throughout the rest of your career (think about admitting patients,
consultants, etc.). In the ER, we do more focused presentations than on other services.
Look at this website: https://www.emra.org/students/advising-resources/patient-presentations/ 

Dr. Margaret Goodrich is a Medical Education Fellow at UMMS-Baystate Department of Emergency Medicine and an expert on excelling as a learner in EM.