How to Succeed in the Emergency Medicine Rotation: Tips for Medical Students
Updated: Jun 23, 2022
In the next six months, thousands of emergency medicine rotations will be completed by medical students hoping to pursue a career in the specialty. NRMP data indicates that emergency medicine residency programs place great emphasis on clerkship performance as a factor in making interview decisions. In a survey, program directors gave "grades in the EM clerkship" a mean importance rating of 3.9 on a scale of 1 (not at all important) to 5 (very important). The only factor given a higher mean importance rating was a letter of recommendation in the specialty. Given the importance of the EM clerkship performance in the residency selection process, I am often asked for advice on how to do well during the rotation. Below are 10 ways for you to make a strong impression.
Identify Common Symptoms Encountered in the Emergency Department, and Develop Approaches to Evaluating These Complaints
Well before your EM rotation, I recommend that you become familiar with common symptoms encountered in the ED. Develop differential diagnoses for these symptoms, and consider how you would evaluate these symptoms in a focused manner. If you're able to do so before Day # 1 of your rotation, you will be well on your way to making a favorable impression.
Review the Standardized Letter of Evaluation
If you're planning to pursue a career in emergency medicine, you will have to submit the standardized letter of evaluation as part of your residency application. This is a form letter created by the Council of Emergency Medicine Residency Directors which allows letter writers to readily compare your performance with your peers, and provide programs with your potential for success as an EM resident. To maximize your chances of receiving the best possible letter, it's important to be familiar with its contents. You can use this knowledge to highlight important skills and qualities during your shifts. You can access the letter here.
Trust your Instincts
As an important part of the team, you will have the opportunity to evaluate patients before the resident or attending physician. If, at any point, you feel that the patient is "really sick," notify your superiors. At times, this will be obvious, as in the patient with hypotension or marked tachycardia or tachypnea. However, not all "really sick" patients will have significantly abnormal vital signs. If you're concerned about something, don't ignore your "gut feeling." Remember that stabilization of the patient always takes precedence over investigation.
Perform a Focused History and Exam
In most rotations, students have the luxury of spending long periods of time performing comprehensive evaluations of patients. In the ED, you will have to change your mindset. No longer will you be able to spend 60 minutes with each and every patient. You must learn how to perform a focused evaluation driven by the patient's chief complaint. One important point - if your patient's chief complaint or presentation warrants the performance of a pelvic, rectal, breast, or genitourinary exam, save these parts of the exam until later when you return with the resident or attending physician.
Your Ability to Present Patients Is Crucial
Think about the case presentation from the perspective of the attending physician or resident. Your superiors are relying on you to provide key information needed to make a diagnosis and exclude other possibilities in the differential diagnosis, including potentially life-threatening conditions. It's your responsibility to ensure that your oral case presentation is logical, follows the proper order, and includes pertinent positives and negatives.
Your ability to present patients clearly and concisely will also play a major role in the impression you make on the resident and attending physician. "The majority of the resident and attending's impression of a student, and ultimately the student's evaluation, is directly linked to how well the student presents," writes Dr. Jeffrey Druck, Associate Program Director of the Emergency Medicine Residency Program at the University of Colorado. Dr. Druck has created an excellent guide to the oral case presentation for medical students in the emergency medicine clerkship.
Be Known for Being an Interpreter and Manager of Patient Information, Not Just a Reporter
I have had many discussions with my EM colleagues about what sets apart top from average performers in the ED. What comes up time and time again is the assessment and plan section of the oral case presentation. By the time students rotate in the ED, most have become comfortable reporting the history and physical exam. Fewer students are comfortable conveying the assessment and plan. To be sure, the development of an assessment and plan is more difficult, and your lack of experience places you at a disadvantage when compared to EM residents and attending physicians. However, you must verbalize your thought process, provide a differential diagnosis, and offer a management plan. "By providing your differential diagnosis, assessment, and plan, you will be giving your supervisor greater insight into your knowledge base and thought process," writes the Clerkship Directors in Emergency Medicine. "Outstanding medical students...have given thought to the differential diagnosis with attention to life-threatening causes and have come up with a reasonable diagnostic and treatment plan..." writes Dr. S.V. Mahadevan, Professor of Emergency Medicine at Stanford University.
Follow Through is Very Important
Following your oral case presentation and discussion of the diagnostic and treatment plan, you may have decided on further testing. Have a system in place to keep track of what you have ordered, and check regularly to see if the results are available. An important part of your follow through is keeping the patient informed of the progress of your evaluation.
Collaborate Effectively with a Diverse Group of Health Care Professionals
You'll quickly see that emergency medicine physicians work closely with a team of professionals. The delivery of high quality care in the ED requires effective collaboration with numerous team members, including nurses, medical assistants, social workers, consultants, and admitting physicians. You will have an opportunity to highlight your skills and qualities in this important area. Remember that, in the Standardized Letter of Evaluation, the Department of Emergency Medicine will rate you on your ability to work with a team. Letter writers will select one of three choices - above peers, at the level of peers, and below peers.
Demonstrate Compassion and Concern for your Patients
Proper diagnosis and treatment is of obvious importance to the ED patient. But so is care, concern and compassion. Emergency medicine physicians strive to care for each and every patient as if they were a family member. As an important member of the team, strive to do the same. Follow-up with your patient regularly. Is your patient in distress? If so, what can you do to relieve the distress? Is there some other need that has not been met? If so, take the lead on addressing the issue or concern.
Be Proactive in Seeking Feedback
Most EM rotations have attending physicians and residents complete shift cards. These are forms on which your superiors will rate your performance in multiple domains. Completed shift cards are submitted to the academic office, and used to determine your overall clerkship grade.
Will you have a chance to see assessments of your performance? Research indicates that 2/3 of emergency departments permit students to view completed assessments at varying points during the rotation.
Since you will often not be able to view these assessments until considerable time has passed, I urge you to be proactive in seeking feedback during or after each shift. Your goal is to understand what you're doing well, and identify areas in which you can improve. Ask your attending physician specific questions. Examples include:
Do you have any suggestions on how I can improve the quality of my oral case presentations?
I am working hard to improve my notes. Do you have any suggestions on how I can improve my documentation?
Thank you for the opportunity to perform the [procedure]. How can I continue to improve my skills in this area?
Through this process of soliciting and receiving feedback, you will be able to make the most of every shift and build upon each experience. If you identify troublesome areas, you can determine how best to remedy the issue or issues. This will help you make the most favorable impression during subsequent shifts.
More tips for the emergency medicine rotation success can be found in our podcasts:
For more information on how to succeed in rotations, please check out our other posts in this series:
Dr. Samir Desai is the co-creator of the online course The Residency Interview 101 and the author of The Successful Match: Rules to Succeed in the Residency Match. He has been a faculty member in the Department of Internal Medicine at the Baylor College of Medicine for over 20 years, and has been the recipient of numerous teaching awards
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