Studying and Clinical Rotations: How to Find A Balance

Unless you try to do something beyond what you have already mastered, you will never grow.

Ronald Osborn, teacher and writer Once again we're talking about balance. This time it's regarding how to find balance during 4th year clinical rotations.  Within the past week, I have switched teams for my Internal Medicine rotation. It has it's advantages and disadvantages and although it's already been five weeks, I cannot honestly admit that I have found a routine just as yet. I will say however, that since I've been on this new team, I have found time to find balance which I lacked initially that I can now apply to the remainder of this rotation and carry on to my next rotation which is Surgery.  When we discuss balance, we evaluate ourselves holistically. We take into consideration our daily personal well being that encompasses our physical, emotional and spiritual make up. With medicine and as students this still applies because as we are doing our best to learn and study ways to properly manage and treat patients, we must also know how to firstly, take care of ourselves and our health.  Let's get into it. Here are 6 tips on how to balance studying and clinical rotations based on my first 2 months of Internal Medicine rotation which can be adapted as you switch rotations.  6 Tips for Balancing Clinical Rotations and Studying  1. Read  As we know, as medical students we tend to learn best not simply hunched over a textbook in a quiet spot with Starbucks and a variety of highlighters, but by actually taking care of patients. This last week I had the pleasure of taking care of doctor, who told me that the best way to learn is by examining patients EVERY day and by taking a good history. By spending the time at the bedside, you are actively learning and this is one of the BEST ways to make knowledge stick. Once you've sat and taken a detailed history and constructed a problem list based upon the presenting complaint and the laboratory values and other investigations results, do your best to READ up on your patient and then go the extra mile and read up on ALL of the patients that are on your team or those admitted to the rotation that you're in at the time. Yes it does sound tedious, but as time is limited and you don't have the luxury of spending 8+ hours a day to study as you would have during the first three years, every minute counts. What I've found that works for me is that after gaining as much information as I can from my patient, I try to access Up-to-Date either by mobile or on the wards and read as much as I can about the patients I am seeing first and then those on the service I am on. After doing this, I make notes or questions and then discuss the assessment and plan with my Senior House Officer or Intern and do my best at actively participating or contributing to the discussion on rounds. Also, reading an hour consistently throughout the month helps reduce the need to cram and allows you to construct a plan of care for the patients on your team.  2. Practice Questions Practice questions may be hard to source during the first few weeks, however they are easy to come by if you do your best to network with those in higher years OR simply by searching the internet for exam questions based on the specific rotation you are in. By getting in the habit of answering practice questions EVERY night, you're exposing yourself to a range of questions, some of which you can even ask on rounds which will benefit everyone on your team.  NOTE: By reading intensely during the first half of the rotation and doing lots of practice questions as well as compiling notes, by the week before exams you're able to simply review your notes and the answers to the questions as well as focus on the more important or weaker areas the week of the exam.  3. Early to bed; Early to rise Trust me, you will want to do nothing more but to sleep at the end of each day. You will be mentally and physically exhausted, however try not to crash every day. By getting to bed early after reading and waking up early you would be able to get some reading done in the mornings. Use your time wisely and as far as possible abandon the thinking that what reading you did not do or complete the night before will be done the next day. It seldom happens and what you'd want to do this year is to tackle the work as it comes rather than letting it all pile up.  4. Take advantage of the down time While on call do your best to get things done. Be it working on your clinical examination skills for OSCEs or completing other tasks that may be required for your school. Accident and Emergency is the ideal place to work on venipuncture, peripheral line insertions, inserting nasogastric tubes an catheters and watching procedures. I was able to get some of these things signed off on, in less than an hour and gained the confidence as well. During call hours, make use of the time you have to read as well and to study, these times are ideal for learning normal reference ranges and interpreting laboratory data.  5. Ask questions Questions are ways by which we learn. Gaining the confidence to ask them on rounds may take time especially if you spent the last three years as a small fish in a big pond (in a class with 200+ students). Moving from a large class size to a team consisting of less than six people can be intimidating at first but it gets easier with time and the more you read. Whatever you do, DO NOT leave questions that you have (and these are those questions you have after reading articles or textbooks) for later. You will forget, another patient will be added to the team and you'll never know the answer. Take advantage of the teams you may be on that consist of interns or SHOs that LOVE to teach, also, don't simply take their word for it either; be sure to find the answer as well as guidelines and practices often change of which they may not have had the time to look up.  6. Don't lose yourself  Be sure to stay true to who you are. Try not to give up the simple pleasures of exercising, health eating and spending time with family. Schedule a day off and do something other than medicine but be sure you're also scheduling time to study, read and practice exams as well.

Unless you try to do something beyond what you have already mastered, you will never grow.

Ronald Osborn,
teacher and writer

Once again we're talking about balance. This time it's regarding how to find balance during 4th year clinical rotations. 

Within the past week, I have switched teams for my Internal Medicine rotation. It has it's advantages and disadvantages and although it's already been five weeks, I cannot honestly admit that I have found a routine just as yet. I will say however, that since I've been on this new team, I have found time to find balance which I lacked initially that I can now apply to the remainder of this rotation and carry on to my next rotation which is Surgery. 

When we discuss balance, we evaluate ourselves holistically. We take into consideration our daily personal well being that encompasses our physical, emotional and spiritual make up. With medicine and as students this still applies because as we are doing our best to learn and study ways to properly manage and treat patients, we must also know how to firstly, take care of ourselves and our health. 


Let's get into it. Here are 6 tips on how to balance studying and clinical rotations based on my first 2 months of Internal Medicine rotation which can be adapted as you switch rotations. 

6 Tips for Balancing Clinical Rotations and Studying 

1. Read 

As we know, as medical students we tend to learn best not simply hunched over a textbook in a quiet spot with Starbucks and a variety of highlighters, but by actually taking care of patients.

This last week I had the pleasure of taking care of doctor, who told me that the best way to learn is by examining patients EVERY day and by taking a good history. By spending the time at the bedside, you are actively learning and this is one of the BEST ways to make knowledge stick.

Once you've sat and taken a detailed history and constructed a problem list based upon the presenting complaint and the laboratory values and other investigations results, do your best to READ up on your patient and then go the extra mile and read up on ALL of the patients that are on your team or those admitted to the rotation that you're in at the time.

Yes it does sound tedious, but as time is limited and you don't have the luxury of spending 8+ hours a day to study as you would have during the first three years, every minute counts. What I've found that works for me is that after gaining as much information as I can from my patient, I try to access Up-to-Date either by mobile or on the wards and read as much as I can about the patients I am seeing first and then those on the service I am on. After doing this, I make notes or questions and then discuss the assessment and plan with my Senior House Officer or Intern and do my best at actively participating or contributing to the discussion on rounds.

Also, reading an hour consistently throughout the month helps reduce the need to cram and allows you to construct a plan of care for the patients on your team. 

2. Practice Questions

Practice questions may be hard to source during the first few weeks, however they are easy to come by if you do your best to network with those in higher years OR simply by searching the internet for exam questions based on the specific rotation you are in.

By getting in the habit of answering practice questions EVERY night, you're exposing yourself to a range of questions, some of which you can even ask on rounds which will benefit everyone on your team. 

NOTE: By reading intensely during the first half of the rotation and doing lots of practice questions as well as compiling notes, by the week before exams you're able to simply review your notes and the answers to the questions as well as focus on the more important or weaker areas the week of the exam. 

3. Early to bed; Early to rise

Trust me, you will want to do nothing more but to sleep at the end of each day. You will be mentally and physically exhausted, however try not to crash every day. By getting to bed early after reading and waking up early you would be able to get some reading done in the mornings.

Use your time wisely and as far as possible abandon the thinking that what reading you did not do or complete the night before will be done the next day. It seldom happens and what you'd want to do this year is to tackle the work as it comes rather than letting it all pile up. 

4. Take advantage of the down time

While on call do your best to get things done. Be it working on your clinical examination skills for OSCEs or completing other tasks that may be required for your school.

Accident and Emergency is the ideal place to work on venipuncture, peripheral line insertions, inserting nasogastric tubes an catheters and watching procedures. I was able to get some of these things signed off on, in less than an hour and gained the confidence as well.

During call hours, make use of the time you have to read as well and to study, these times are ideal for learning normal reference ranges and interpreting laboratory data. 

5. Ask questions

Questions are ways by which we learn. Gaining the confidence to ask them on rounds may take time especially if you spent the last three years as a small fish in a big pond (in a class with 200+ students). Moving from a large class size to a team consisting of less than six people can be intimidating at first but it gets easier with time and the more you read.

Whatever you do, DO NOT leave questions that you have (and these are those questions you have after reading articles or textbooks) for later. You will forget, another patient will be added to the team and you'll never know the answer. Take advantage of the teams you may be on that consist of interns or SHOs that LOVE to teach, also, don't simply take their word for it either; be sure to find the answer as well as guidelines and practices often change of which they may not have had the time to look up. 

6. Don't lose yourself 

Be sure to stay true to who you are. Try not to give up the simple pleasures of exercising, health eating and spending time with family.

Schedule a day off and do something other than medicine but be sure you're also scheduling time to study, read and practice exams as well. 

Lessons from the Book of Job

This post is a bit delayed, however, it should still be appropriate and right on time for some if not all of you.

My month of reading the book of Job earlier this year revealed the importance of daily devotion and allowed me to see the strength Job gained not just of his faith, but also of knowing his purpose.

There are times when life challenges us beyond our imagination when we feel as though we're not meant to go on; and just when we're about to give up, that little bit of hope that we have left is all we need to reignite our faith in God and knowing that His way and plan is far better than our own even though we're not experiencing the happiest of times.

My dear friend, medical school has its moments, I know that and I hope you come to realize that as well. Life has its moments as well; learn to enjoy both the happy and the bad ones because simply experiencing them is a reminder in and of itself that you're still in the fight.

Thessalonians reminds us to "REJOICE ALWAYS" and yes it may seem as though it's easier said than done, but after you've endured one storm, rejoicing becomes second nature.


All the best for the week ahead and don't be a stranger to the book of Job when you're in need of encouragement and a reminder of what it means to live a life of purpose.

Great Medical Resource

Back in April, I was contacted by Till, who happened upon my blog and took the time to check out my Resources page. He politely informed me of another resource of which I am extremely grateful especially as USMLE preparation can be expensive and Lecturio offers free access to students. 

So this post is a plug for Lecturio. I have also added the link to my Resource page for easy access and would advise you to check it out if simply to look around and explore the free items such as the USMLE QBank. 

Thanks Till for introducing me to another great medical resource! Be sure to check it out guys. 

I am not affiliated with Lecturio in no way and am not receiving any monetary contributions for this post. 

Lessons From My First Month of Internal Medicine

"The only way you are going to have success is to have lots of failures first."-Sergey Brin

With the first month of rotations behind me there are a few gems of advice I'd like to share. Some are things that I've heard from Consultants, the Director of the School or simply what I've gathered from mere observation. 

Year 4 is nothing like the first three years of MBBS in that there isn't a formal structure of lectures, Skills sessions or time that you can schedule simply to study or read. You're now at the mercy of the Consultants, Registrars and SHOs. At times this may be fine and dandy other times, I'll admit I'd rather hang up my coat for the day and read about the pathophysiology of patients illness, but I digress. Hopefully the following would allow you to gain a little more structure than what I had in the first few weeks and assist with a more pleasurable experience. 

General Advice

1. Stick Around

This may seem obvious and all but trust me, it can be easier said than done.

As we were told by the Director of the School of Clinical Medicine and Research, "Medicine begins after 10". By no means am I telling you to stick around until 10 p.m. on a daily basis.  However I am saying stick around at least until 7 p.m.

A typical day of Internal Medicine Rotation for me began at 6 a.m. daily and ended at least by 8:30 p.m. excluding calls.

By arriving to the hospital earlier than my colleagues, I was able to find a spot either in the student lounge or around the hospital where I could gather my thoughts, read up on anything I may not have completed the night before and quickly S.O.A.P. my patients. By doing this I was able to make the Interns meeting that students were expected to attend at 8:15 a.m. and had time afterwards to either meet up with the team or make a quick stop to my locker before rounds. By seeing my patients earlier, I didn't have to rush to do so before rounds started and had ample time to work on my presentation for rounds in the event we rounded.

Sticking around also allows you to get some experience with drawing bloods, seeing or performing some procedures like DREs or catheterizations and participating in a code. It also shows your enthusiasm to learn and that you're an active team player.

2. SLEEP

As medical students we are known to go days on end without sleep. Regardless of what you may have heard from whomever, reducing the hours of rest your body gets is ridiculous and not wise at all not even in the name of medicine. 

Trust me, I have said it repeatedly to myself and to some of my friends, I don't know where the Consultants expect us to pull more hours from in a day to be actively participating on the wards, reading up on every patient and still have time to study for exams. That's before I got smart. 

It's easy to complain and make excuses and to cry or scream over spoilt milk, however, in doing so, you're simply wasting time. It wasn't until I started to plan EACH minute of my day that I realized it is doable to stay abreast of each patient on the service, assist where you can on the wards and still have time after leaving the hospital, eating dinner and showering to study and still get a good night's rest all to do it again. 

By getting adequate rest and I'm talking about 6 hours each night, you're allowing yourself to be well equipped for the day ahead and limiting yourself from getting sick. 

3. Be a Team Player

Medicine is all about team playing. Needless to say there are some who overlooked the memo when they initially applied for medical school and they end up learning the hard way once clinical rotations begin. 

No one wants to be on a team where the members aren't team players and are constantly throwing each other under the bus. It looks bad, makes it awkward during rounds and the rotation becomes hard to endure. By trying to be more a team player early on in your medical career, it will go a long way when you start your clinical rotations. 

The team doesn't only consist of the Consultants, Registrars, SHOs and Interns; it also consists of every person who is involved in the well-being and care of the patients on your service and yes that includes the nurses, laboratory technologists and technicians as well as your Imaging personnel and even housekeeping. 

I've learnt that by being around actively on the wards after rounds are completed, to assist the intern and even the nurses on the wards that a simple act of willingness to help where you can goes a long way in your favor in the end. By assisting your intern, you're lightening their load which allows them to be available to teach you a thing or two. 

4.  Don't take shortcuts

This should go without saying but I'll still mention it. 

Medicine is not about shortcuts. Clinical years are all about making the most of your times on the wards and enjoying a new means of learning and experiencing the facets of medicine. 

Dedicating time to learning certain things will ensure you're not skimming on any area. Each rotation is vital despite the fact that some are more interesting than others. 

If you start your rotations with the thought that you can take shortcuts and will get by, think again. It will show in one way or another. Be it on your written examinations or your OSCE. 

For medicine we're expected to know each person assigned to the service and to be prepared if called on during rounds to present that person. It sounds like a lot, but let's think about it. If you're in the hospital and you're assigned to a team responsible for your care and management, wouldn't you want each member of that team to be knowledgeable of your situation? 

By ensuring you dedicate necessary time to each aspect of your learning will ensure that you won't have a need to take a shortcut. 

5. Do EVERY procedure offered

Although this may seem a bit far fetched you'll be glad you took my advice here if it's the only one. 

As students we're expected to know certain things and have a willingness to assist where possible. We also believe that we'll possibly see a procedure again at some point before we graduate medical school and would have countless opportunities to perform them. Erase this thought from your head right now. 

Think of each patient and procedure as being your first and last encounter because the reality is you don't know when you would see something or have the opportunity to do it again. 

From inserting IVs, drawing bloods, catheterizations, DREs get in as much as you can now. By the time you graduate and become an intern, everyone will expect you to know how to do them and they won't be smiling when you're all hesitant and nervous because you never took the time to perform certain procedures as a student. 

All in a Day's Work

"You must do the thing you think you cannot do."-Eleanor Roosevelt

My first month of Internal Medicine is winding down and without fail I've had the opportunity of performing my first Digital Rectal Examination (DRE). Needless to say, I was beyond uncomfortable and although my patient did not let on and was very compliant and accommodating, so was he. 

I've been following this patient now for a week and I must say, there are times when I am exhausted, cold and hungry and would love nothing more than to retreat to my bed with the covers pulled up to my neck and tucked in tightly all around; however, the one thing that disturbs me to the core, disrupting my daydream and selfish retreat is the fact that there is someone, lying in a hospital bed on a ward being attended to by the team I am apart of who will more than likely (or so I would like to believe) take note of my absence. This is the most rewarding part of my Internal Medicine experience. 

Now that I've gotten that off my chest, let's take a look at the DRE as far as when, why and how it is done. 

Let's talk about the DRE.

A Digital Rectal Examination is an examination of the lower rectum and internal organs such as the prostate gland. This procedure can detect any abnormalities of the prostate gland in the male, such as an enlarged prostate; detect the presence of tumors, to obtain feces for a fecal occult blood test which is used to monitor gastrointestinal bleeding or possible colon cancer, to assess the function of the anal sphincter in the presence of fecal incontinence as well as to assess the extent of hemorrhoids. 

The process doesn't require any instruments or fancy equipment; rather gloves and a lubricant are all that are needed. 

The examination will require the patient to be disrobed and also in a comfortable position, such as lying in the fetal position with their knees to their chest/chin. 

As the examiner you will then insert your gloved and lubricated finger into the anus and then into the rectum gently rotating younger finger so as to examine the posterior part of the prostate and the surface. You are to comment in your notes whether or not it is firm (which can be described as the feeling of the tip of your nose) or hard (which can be described as the feeling of the tip of your elbow). You are also to comment on the surface, whether or not it is smooth, bumpy, nodular etc. 

Throughout the examination it may help remove the awkwardness if you would reassure the patient that they are doing fine, and of everything you're going to do and are doing. 

Once you're done and your finger is removed be sure to comment in your notes on the contents that may be on your gloved finger. Be sure to thank the patient, discard all soiled materials and cover the patient. 

I will admit, it helps a lot if you at least appear confident in what you're about to do and if the patient is accommodating and understanding of what you're about to do and why. 

Hey Doc!

"The speed of your success 

is limited only by your dedication 

and what you're willing to sacrifice."

-Nathan Morris, Financial Coach and Writer

As a fourth year medical student, I have found a greater appreciation for and the practice of medicine. Monday will mark the start of my third week and never did I imagine how much I would love this experience minus the 'pimping'; although it has allowed me to decrease my response time and allowed me to improve the skill of thinking on my feet when faced with back to back succession of questions. 

My first two weeks consisted of practicing history taking, seeing how much things which I considered "necessities" I could stuff into the two small pockets of my white coat, approximately 5 codes, 2 of which I actively participated in and realized that in the heat of the moment, saving a life or doing as much as I can to assist in the resuscitation process gives one a greater sense of what it means to be a doctor and how fast things can deteriorate unexpectedly. 

After a full week of witnessing first hand, the facets of death I have found it hard to grasp how easily my seniors have become desensitized to the needs of their patients. It's heartbreaking to stand with a team as the care and management are discussed with patients and their families casually as if they're not even human, having to later return to their bedside to apologize for someone's poor use of a word or the rude manner in which they addressed a patient. As a student, I have been blessed to have been apart of a system, that diligently works to change the mindset of the medical students and future Physicians, ensuring we learn how to properly and professionally communicate with patients, their families and most importantly to each other. 

It's easy to see that when a system fails which seems to be the case in most third world countries where the public sector is burdened by overwhelming numbers of patients and inadequate levels of supplies and equipment, how one can become detached from the humanistic aspect of care; but at the same time it is no excuse to practice bad medicine or to deprive patients from treatment based on what one perceives to be their financial status. As the weeks pass and patients leave the service, a little piece of their history remains with me and I am able to address another with a bit more care and concern than the last. 

Medicine requires a lot of sacrifice, commitment to service and the ability to get along with not just my peers but also everyone who is apart of the care and management of each individual I have the privilege of speaking with and examining.