Grades in med school clinical clerkships are partially subjective. This may be a frustrating contrast to the more objective grading system of preclinical years. Here are some tips to help you shine.
Understand the critical importance of your clinical performance during medical school
While board scores are the most important determinants of where you are offered interviews, clinical performance also contributes to 3 of the top 6 most important factors program directors use when deciding who to offer an interview. Namely, clinical performance contributes to your (1) letters of recommendation in the specialty, (2) medical student performance evaluation letter (MSPE, which is a summary made by your advisory dean at the beginning of your final year, of all of the written evaluations you have received throughout your major med school clerkships and activities), and (3) grades in required clerkships.
Understand how your clerkship is graded
What percent of your overall clerkship grade is determined by subjective evaluations? Who performs the evaluations? The residents? Attendings? Fellows? Nurses? Do you have to request evaluations or are they automatically requested for you? Is there a shelf exam? How much weight is given to the shelf or other final exam? Are there quizzes?
Are there clerkship evaluation forms you can take a look at? Often, you'll be shown the forms your residents and attendings will use to evaluate you.
Figure these factors out, as they varies greatly across institutions and clerkships.
Understand the determinants of clinical performance
Your evaluations will largely be dependent on subjective assessment of the following qualities your colleagues see in you.
(1) Affability
Introduce yourself to each team member on your first day. Introduce yourself to other care providers as you meet them in the context of clinical care. Shake hands, make good eye contact, and smile. Be interested, respectful, and present. Be honest, open, and non-judgmental. Be genuine.
Be yourself while also meeting your resident at their level. For example, if your resident is very talkative and extroverted, and you are shy and introverted, know that you will come off as shy and introverted unless you make at least a small effort to come out of your shell a bit. If your resident is stressed and busy, focus on trying to be efficient, helping out where you can, and know that that asking too many questions when things get hectic will annoy your resident.
(2) Communication
Assessed based on your oral presentations of HPIs, written notes, ability to build appropriate rapport with team members, patients, and families, and overall sense of your communication skills as demonstrated with team members.
Face those who are speaking to you and make good eye contact. Lean in while listening. Do not interrupt. Think before you speak.
Be focused: don't randomly bring up unrelated topics or personal matters unless everyone is already chit-chatting.
Ask for expectations on the first day of the rotation. Are you supposed to do the whole HPI on new patients and write up all the notes in the electronic medical record system? Are you supposed to see follow up patients? What tasks can you help out with during the day?
Listen and summarize back instructions you are given to team members, e.g.,"Ok, sounds good, I'll go and examine Mr. Smith and will be sure to ask about his history of drug use." Immediately ask for clarification if you don't understand an instruction you were just given.
Speak straightforwardly with confidence on that which you are certain. Communicate uncertainty about that which you are uncertain. Be honest and open. Say you do not know or did not ask if you don't know or did not ask.
(3) Work ethic/Dedication
Be prepared. Know your patients better than anyone on the team. If your patient has a rare condition, spend half an hour reading up on it.
Be present and available. If someone asks if you're able to help out with something, say yes if you can, while making sure not to volunteer for things you don't know how to do yet. For example, on a surgery rotation, you may be asked to manage a patient with a wound-vac. If you don't know how to change the wound dressing for a patient with a wound-vac, and you're asked to do it, say you've never done it, and would love to learn how to do it.
(4) Professionalism
Be punctual, well groomed, and appropriately dressed. Be interested. Look for opportunities to take on new responsibilities while understanding your limitations as a medical student.
Be genuine. Be kind to everyone. Be non-judgmental. Listen emphatically to the concerns of colleagues and patients. Be receptive and actively respond to feedback without being defensive. Ask for feedback.
(5) Competence
Raise up to the level of competence expected at your level of medical school education. On the first day of your first rotation, expectations will be low. On the last week of your sub-internship, you will be expected to perform at the level of a intern. Early on, focus on developing competence at performing a comprehensive, focused, and supervised H/P, presenting an organized and brief HPI, understanding the indications and interpretations of lab tests, procedures, and diagnostic studies, and formulating a reasonable assessment, differential diagnosis, and plan.
(6) Fund of knowledge
Study every night, focusing on getting through the key resources specific to each clerkship sooner rather than later.
See clerkship specific tips on how to prepare for, and which resources to use during, the medicine, pediatrics, OBGYN, psychiatry, and surgery clerkships.
Ask for evaluations and letters of recommendations appropriately
If you're really enjoying working with an attending, have worked with them for at least a week, and have presented an HPI to them on which you received positive feedback, consider asking the attending for a clerkship evaluation (if your school allows you to ask for evaluations). If you really think you have shined, consider asking for a letter of recommendation. Ask, "I've really enjoyed working with you and was wondering if you would be able to write a strong letter in support of my application for X residency". Asking for letters of recommendation will be covered in a future post.
Don't let a disappointing evaluation get you down
The cause of a poor or disappointing evaluation are multi-factorial and highly rater dependent. Maybe you thought you shined but got a terse evaluation from a busy attending or resident who tried to fill out your evaluation as quickly as possible. If the evaluation was strongly worded and negative, make sure you talk to your clerkship director or the person who evaluated you for more feedback in an effort to better learn how you can improve. Focus on continued improvement with the goal of becoming the kind of doctor you would want taking care of one of your family members.
Final thoughts
Be genuine. Be professional. Smile, and be interested and engaged. Be prepared and study nightly. Enjoy your time in the clinic!
