Orienting New Medical Students

An approach to welcoming medical students to their first day of a new clinical rotation

About a month before I graduated from medical school, I started a new note on my phone that I named “Things Medical Students are Worried About.” I was afraid–though this did not independently make the list–that the stresses of internship would erase my memory of what had made being a student so difficult, and I wanted something I could refer back to when I needed a refresher on all the challenges my students faced but would be too polite to remind me of themselves.

The “Logistics” category of my note filled out quickly with questions like “Where do I go on the first day?”, “Who will be there to meet me?”, and “How do I know when it’s time to leave?”, alongside concerns about when to eat, where to find nurses, and how to navigate the floor.

The “Meeting Expectations” category, though, was more abstract: “Which patients should I follow?” “How do I know which tasks are appropriate for me?” “How can I tell if my resident is mad at me?”

Looking at the list years later, I’m struck by how I underestimated the grace most residents extend to their medical students. I wanted badly to know everything there was to know about a rotation from the moment I arrived, which blinded me to the fact that my residents would expect–and accommodate–an adjustment period.

Still, the list evokes some parts of the medical student experience I have not forgotten–the self-flagellation after making small mistakes that now I realize the residents had barely noticed, the way a single “Strong work!” could provide all the sustenance I needed for days.

With that in mind, I developed a day-one orientation for the medical students who joined my clinical teams, designed both to anticipate their questions and allay their anxieties as they worked to adapt to yet another team’s way of doing things.

Introductions

Introductions usually started a day or two before the rotation began, when students would send a text or an email asking where and when they should plan to meet the team on their first morning. I would tell them to come in an hour after the interns and I did, which both allowed me to get some chart checking done and meant that they would arrive at a moment when I was not distracted by the night team’s signout. If they referred to me as “Dr. Liebling,” I would ask them to call me “Simon.” And while I would give them directions, I would encourage them to call after emerging from the elevators on our floor in order to spare them the scavenger hunt for another scarcely labeled workroom.

Getting Set Up

Once students arrived, my first priority with rounds looming was to make sure their EMR was appropriately set up so that they would be able to follow along as we discussed each patient. I would show them how to save the appropriate patient lists, how to log in to the right chat groups, and where they could find any needed note templates. I was also explicit about our expectations of them for the first day–there was no need for them to scramble to prepare a presentation about a patient they barely knew, but I wanted them to listen closely to rounds to identify patients they might be interested in following thereafter.

Goal Setting

When time allowed–usually after rounds–I would sit with the students for a longer conversation.

First, I wanted to know about the extent of their prior clinical experience–which other rotations they had already completed, and whether they were just starting their internal medicine rotation or were in the middle of it, which helped me calibrate both my expectations and my teaching plan for our time together.

Then I would ask them to self-generate a list of things they wanted to work on during the rotation, which I would write down for reference during our later feedback sessions. I would push students to be as specific as possible–“I want to improve my presentations” is a perfectly reasonable goal, but “I want to do a better job selecting pertinent lab values to include in my presentations” allows for more precise observation and coaching.

Expectations

Only after students set their own goals would I share my expectations for them, which I structured as an outline of a typical day. The start of their days would mirror an intern’s, with prerounding and notewriting. I would pause here to explain how I would be available to them each morning. While some senior residents offer to review an entire patient presentation with their medical students before rounds, I would not, on the grounds that it turns the presentation into the recitation of a script rather than an opportunity to display original thinking and grow comfortable with adapting on the spot to new information. Instead, I would offer to discuss any specific questions they had about their patients, whether involving the interpretation of a new lab value or the refinement of an assessment and differential diagnosis.

After rounds, they would be invited to join the rest of the team as we ran the list and reviewed the tasks for the day, when they would be welcome to volunteer for tasks they felt comfortable completing. Recalling my hesitancy as a medical student to take on tasks that I didn’t already know how to do, I would reassure them that the rest of the team would be more than happy to walk them through anything they wanted to learn to do that was not already familiar.

Anticipating the Anxiety

When I was a medical student on my internal medicine rotations, the workrooms were arranged so that we sat in chairs along one wall, facing the backs of our residents as they used the workstations across the room. I remember hours going by without them turning around to talk to us, while I sat in mounting fear that I had done something to upset them. It took all of one day of intern year to realize what had actually been going on–they were busy and stressed beyond measure and had simply forgotten–or were too overwhelmed–to engage us.

As a senior resident, I would name this fact explicitly when orienting new medical students, sharing my own memory and reassuring them that any time that we left them languishing without something to do was a failure on our part, not a reflection on their standing with the team. I would encourage them to use that downtime however they wanted–working through UWorld, tending to emails–without feeling like they needed to conceal it from the rest of us. And for the all-important question of dismissal at the end of the day, I would promise to be attentive to sending them home once the day’s educational value had been exhausted, but that I would never be offended if they checked in with us whenever it seemed that they distractions of our clinical responsibilities had led us to keep them longer than intended.

Wrapping Up

The clinical year of medical school is uniquely destabilizing, as students are forced to effectively change jobs every few weeks, shunted into new workplaces with unique customs, vernacular, schedules, and expectations. The value of a structured orientation on day one, I think, is that it normalizes the discomfort and unfamiliarity inherent to that kind of professional upheaval, assures students that they will settle in with time, and makes clear that they have friendly resources available to them as they do. And without seeming too lax, it allows residents to make clear that they were medical students once too.