How to Approach Third Year (M3) as an EM-bound Medical Student

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Author: Taylor Petrusevski, MS4
Loyola Stritch School of Medicine
AAEM/RSA Publications & Social Media Committee

You made it through the seemingly endless lectures and question blocks that consume the pre-clinical years of medical school. In third year, it’s time to bring your classroom knowledge to the bedside. It is an exciting and overwhelming transition, but it is such a transformative year and a pivotal point in your training. You are building the foundation of your clinical skills and the formulation of your practice patterns start now. Among many variables, including Standard Letters of Evaluation (SLOEs), performance on the emergency medicine (EM) clerkship, interviews, and Step scores, third year clerkship performance continues to be an important parameter that program directors use when evaluating candidates.[1] While some studies note that your third year clerkship grades do not carry as much statistical weight as these aforementioned application components, your third year clerkships serve as the foundation of clinical skills that will allow you to succeed on your EM rotations, which is heavily weighted.[2] There are several methods to successfully navigate this transition. Different learning models emphasize the best cognitive practices to bridge this transition, noting that active reflection is just as important as preparing and actually getting the clinical experience.[3] Ultimately, do what works for you. Here are some suggestions on how to approach M3 as an emergency medicine (EM) bound student:


Challenge yourself to “be that specialty” on each clerkship
The beauty of the breadth of EM is that EVERY clerkship is “relevant.” From psychiatry to surgery, you will use some skillset from that rotation in practice. As an EM physician, you have a distinct skillset that allows you a wide breadth of knowledge. The foundation of this skillset is born throughout all of your clerkships. By fully immersing yourself in that specialty, you will not only become a stronger, well-rounded student but also a better EM applicant and physician. You’ll create a skillset and fund of knowledge that you can call upon and filter to the EM perspective when seeing your first obstetric or psych patient, among others, in the Emergency Department (ED).
So how do you fully immerse yourself in each clerkship?

• Identify what the “bread and butter” patient cases of that specialty are and see them. This doesn’t mean you can’t challenge yourself with a zebra case, but make sure you have the common workups down too. To do this, let your residents, attendings, and readings guide you. 
• Learn the distinct history and physical (H&P) for that specialty and use it when seeing all of your patients. An obstetrical (OB) H&P is very different from your general surgery H&P or your psychiatry H&P. Learn and do the nuances of each, and you will be able to filter from each what is relevant and practical from the EM perspective. 

This is challenging, and there will be clerkships that test you more than others, but you will come out a well-rounded EM bound medical student.

Hone your oral case presentations throughout the year 
Presenting patients is a skill, and just like any procedural skill, takes practice. Your case presentations will evolve throughout the year, as you learn what information to filter based on the clinical situation. Listen to how residents and attendings present and discuss patients to learn what to filter. Ask for critical feedback on your presentations and challenge yourself to apply those changes the next day on rounds or clinic. This way, by the time you do your EM rotation you will have a keen sense of what is pertinent to communicate a concise but thorough presentation. This will not only make you stand out but is a skill you will use the rest of your career.

Take full ownership of your patients 
Taking on additional patients will allow you to learn more and practice presenting, but also challenge yourself to fully own your patient from start to finish. Come up with your own management plan, know what is pending, and take initiative to see them through until their final disposition. Volunteer to call any consults, update their family, and review any discharge paper work with them at the bedside. If something seems to be stalled, take initiative to call down to the lab or radiology to see if you can help. This will help you when you’re managing several patients in the ED at a quicker pace.

Be adaptable & be uncomfortable
A skill especially relevant to EM-bound students, being adaptable will allow you to navigate new and uncomfortable clinical situations with ease. While it will come more natural as you progress throughout your third year, keep an open mind and take real-time feedback from your residents and attendings in stride, trying to apply it both in real-time and the next time you face a similar situation. You learn the most when you’re uncomfortable, so push yourself to always step outside of your comfort zone. Whether that is practicing a new procedural skill or seeing an unfamiliar patient presentation, being uncomfortable will make you grow and allow you to eventually be comfortable in uncomfortable situations, something that distinguishes EM from many specialties.

Don’t do it just for the grade
Yes, grades are important. But how you carry yourself clinically with your patients, residents, attendings, and colleagues matters just as much, if not more. Learn as much as you can and perform your best because that is what your patient and team needs, and the good grade will come. Some of the most valuable rotations may be hard, notoriously “lower grading” rotations but they push you in ways that will make you a stronger student and physician in the long term.

Integrate relevant EM resources to each clerkship 
You will come to find there are a myriad of excellent EM resources, many of which are free and accessible in the era of Free Open Access Medical Education (FOAMed). As you get more comfortable on your rotations, you can integrate relevant EM resources into your learning so that you are still studying relevant material for that particular clerkship but tailoring it to an EM perspective. On OB listen to a podcast on the EM management of ectopic pregnancy, on neurology review the management of ischemic and hemorrhagic strokes, on surgery the differential diagnosis of the acute abdomen. You can also make a separate, academic twitter account for yourself in the beginning of third year, solely for the purpose of becoming familiar and navigating different aspects of FOAMed. EM resources to get you started include not only the AAEM/RSA Modern Resident blog and podcasts, but also EM:RAP podcasts, which are included in your AAEM/RSA membership.

M3 is full of ups and downs, but enjoy the journey and most importantly, the privilege of all of the patients and teachers you get to learn from!



References:

1. Lotfipour S, Luu R, Hayden SR, Vaca F, Hoongpongsimanont W, Langdorf M. Becoming an emergency medicine resident: a practical guide for students. Journal of Emergency Medicine. 2008 Oct; 35(3):339-44
2. 2. Neegard M, Assimacopoulous E, Harland K, Van Heukelom J. Emergency Medicine Selection Criteria: An Update and Comparison. AEM Educ Train. 2018 Mar 22;2(2):146-153. 
3. Greenberg L, & Blatt B (2010). Perspective: successfully negotiating the clerkship years of medical school: a guide for medical students, implications for residents and faculty. Academic medicine: Journal of the Association of American Medical Colleges, 85 (4), 706-9 PMID: 20344392