How to Impress your Attendings in 2020

Welcome everybody. Uh My name is Amine Azam.

I am a teammate here at Osmosis. I'll be serving as your moderator today.

Um You can see and I, I'm on faculty at UCSF in the Department of Psychiatry and Behavioral Sciences. I'm also on faculty at two other San Francisco Bay area Health Science Universities and uh I receive 15% salary support from osmosis.

Um I'd like to introduce our panelists and you're gonna hear mostly from the four of them today. So Arsen Asuncion uh comes to us from N IU Lago Health and she's in pediatrics and the Assistant Dean for Clinical Education and also involved in pediatric clinical care.

Thank you, Arsen Poum. Uh comes to us from uh emergency medicine at Vel Cornell Medical College where she works at in a New York Presbyterian Queens and she has a fellowship trained in emergency ultrasound and also board certified and lifestyle medicine.

And as you see, she also is an active social media blogger with her followers. Our other two panelists are Roger from uh the co-founder of Med Cram, but also at UC Riverside School of Medicine.

And you can see as you look at his bio that he's uh he's been a preceptor to pa students as well as medical students and um have been at Loma Linda and has a background in sleep medicine.

Um and currently a pulmonologist uh at the Beaver Medical Group. Lastly, Francis is from uh the Ny U Long Island School of Medicine and Chair of the Family Medicine Department.

Um and his clinical focuses on primary and preventative care. What I hope you'll hear from our panelists is they have a diversity of experiences and expertise um in today's uh panel.

So we're eager to hear from all four of their voices. The structure for today.

I'm gonna be vigorously keeping time so that we can get through all of these topics. But you can see that we hope to cover these five global uh topics uh with those allocated time stamps and then we hope to have uh left 10 minutes at the end for your questions.

You're welcome to put the questions in chat throughout the talk. Um And then our osmosis teammates will uh sort of queue them up for us at the Q and A portion.

So the conversation today is gonna be uh uh both about uh you know, the current COVID global pandemic. But also our panelists may also share their reflections about sort of uh pre COVID and hopefully in that soon to be imminently, future post COVID.

So, and we're gonna rotate, who goes first for each of these. So Arsen has got the first question first.

Um how is the COVID-19 pandemic infected impacted your institution and clinical experience for the med students? Take it away.

Arsen, thank you very much. Um I just like to uh say thank you everyone uh for joining this um this zoom um you know uh conference.

So um actually, at the impact of um COVID-19 here in New York, uh uh we are in New York actually in New York State. So I was actually a pediatric clerkship director at the time because we were doing this um medical school in connection with Stony Brook.

But now we have our own medical school, which is the Ny U Long Island School of Medicine. So we were on the verge of last of our graduates for the in uh Stony Brook medical students.

So during the time when we have the COVID uh pandemic coming in, we, we really don't know what to do with our student, to be honest with you, right.

So we were on the verge of asking what AMC wants us to do. What are the things that we want to?

At first, we thought that we want our student uh especially those who are fourth years to be actually on the LA on ba ba basically doing clinical as you know, as we were detected that however, there was content, there was a big surge.

So what we did for them is that way we stopped all the clinical rotation. That's what actually what the administration wants us to do and what also the AMC recommendation.

So that's what we did. And as a clerkship director at the time for pediatrics, which I have like fourth year students who are doing their Sabai and also doing their advanced clerkship.

I have to actually come up with a way how to deliver education for the students during COVID. So one of the things that I did, we have a lot of uh things available for case based learning through online or web um or web based web based module.

So one of the things what I did is that I assigned, I went through all the different um web based um you know, materials that I could go through.

So example, osmosis, I did also aquifer. I did a lot of uh also a lot of things also from concept, which is a pediatric uh clerkship uh website um education program here in the US, which is available.

And I think it's available for everyone if you take a look that we found cases there. And I, for example, one of my clerkship, advanced clerkship was wants to do an emergency medicine, pediatric emergency medicine uh rotation.

So what I did, I found case, I find cases for him and assigned him cases online. And then if he has any kind of questions about that, we go back together and go through using webex altogether.

So that's one of the things that we did uh for them, the other thing that we were running during the time was what we called the um I think it's called the transition to clinical uh transition to residency, which are the fourth year student going in preparation for the residency.

So what we did, we did also all those lectures through webex and we actually did there also online. So we kind of have a simulation.

We kind of give them the case, show them vital signs um online and let, just let them actually join a Zoom call or a Webex call.

And that's what we did for them to do their simulation. So I see you lots of innovation and creativity there just to keep us uh hearing from other sites too.

Let me just ask Francis if he would share anything else from his perspective. Sure.

So, um and again, thank you all for uh having me and thank you all for joining um doctor since Sean and I come from the same um from the same uh institution um a little bit different.

So I'm, I'm not gonna, I'm just gonna add on to what she had said. Um We stopped clinical rotations in uh in mid March.

And as far as uh II was, I did have a clinical rotation uh in the new medical school at that time. So we took them out of rotations.

And what we did was um I took the opportunity to um give some preventative lectures at that time. And since most of my outpatients practice has started um doing a lot of focus in telemedicine and telehealth.

What we did was I um I organized a, a telehealth series with the, with the students. And um we also did some where, where the students um examined and, and um saw patients via, via Webex et cetera.

And one final thing, one interesting thing what happened here as we were transitioning or we were part of the Stony Brook School of Medicine is those students graduated early and came w and came and worked in our hospital um for two months before they started their residency.

So it was very nice to train them and then ultimately just started working with them right in the, in the midst of the COVID pan COVID pandemic.

I definitely heard some of those discussions around the workforce needs in New York and Metro area and uh graduate early and dive right in early things.

Roger. How about from your side of the United States?

Yeah. So I'm out here in California and um faculty over at low Melinda University also practicing not at the university medical center but in a community hospital.

So it was kind of a little different um at the community hospital. It's a fairly large community hospital, Redlands community uh where I work.

There wasn't a lot of students, students don't rotate through there. They rotate at the medical center.

And so from a, from a community hospital standpoint, we saw more along the lines of, of ramping up the nursing have to uh we, we created two intensive care units, a uh a COVID intensive care unit and a regular intensive care unit.

And so from that pool of nurses, they had to staff both. So there's long hours um in our, in our uh department of about four or five intensivist, we had to basically rotate through two intensive care units.

So it was quite busy on the other half of it though, on my academic head, if I were to put that on, uh the, the lectures still were going on over at Loma, I was responsible for doing the clerkship um education.

So every week, the third year medical students who are rotating on internal medicine would come and get a subspecialty of internal medicine lecture and, and the pulmonary lecture was still having to, to go on.

Of course, what we had done um is part of my role at med is we had, we had already uh come, come up with a flipped classroom model where they would review the notes online, they would see a whole lecture, the lecture that I would normally have given 20 years ago, they, they see it online and then they show up to the lecture in person pre COVID and we would go and fine tune those points.

It's a, it's a model that osmosis has used and that, and we've used as well. It's actually, I believe the future of medical education.

So in actuality, we really didn't have to change much because when the time came during COVID for that Pulmonary lecture, the students came in, they, they already had the same assignment except this time that flipped a class of approach where we had to sort of normally be there in person.

We simply just did that on a zoom meeting. So it really wasn't that much of a different uh feel to it, but it, it worked well.

Roger, thanks for mentioning sort of the flip classroom concept, definitely emerging in a lot of health professional schools globally.

Um where you flip the lecture and the homework effectively and I agree with you, there's a lot of co curricular resources, preexisting materials that can be leveraged in a global pandemic pun.

How about on uh how about for you? Hi.

So I'm an emergency medicine physician. I work at near Presbyterian Queens.

What happened at our institution which I'm very, very impressed with. They worked very hard to help the medical students get the best possible education during the pandemic.

And what we did is we have a highly interactive rotation that was case based. Did the students have about 4 to 5 hours of daily learning?

It is lectures that are presented by our core faculty, by residents and by fellows. So these are in interactive lectures where they get to meet our core faculty, they get to meet our residents, they get to meet our fellows.

And because it's in interactive while they're teaching, they can ask questions. So we get to know the medical students.

You know, we don't want them just to be looking at a screen where they don't get to interact with us. We wanna get to know them and we want them to get to know us, especially if they're choosing our program down the road to apply to.

Also, what I'd like to mention is that we also have procedure labs or simulation lab and we've done, made that into a webinar.

So it's very interactive. Again, they can ask questions, it's live streaming and so is our ultrasound section as well with our ultrasound director also live streaming the ultrasound education.

And after that, the way the medical students can also, you know, I guess, quote unquote impress the attendings is they'll have a 10 minute um presentation at the end of their rotation where they get to, you know, show off what they've learned, show off their skills and get to know our attendings, one on one over there as well.

And we have a questions uh exam at the end where we can assess their knowledge. So we've done everything we can to try to present them with education, how they can get to know us, how we can get to know them and then assess their knowledge.

Um I would just share that sort of wearing my uh my fellow academic hat with all of you similar constructs at all of the universities that I'm a part of.

Um and I think what I would say by way of summary, as we move to the next slide is what you hear from all of these faculty affiliates, um who are physicians that uh and practicing medicine and teaching is we are all finding the right balance between our patient care needs and our educational needs of our students.

And, and, and it's delightful to hear all of the different innovations that have come from a global pandemic. Question.

Two for the next 10 minutes. We're gonna ask you what one or two recommendations would you personally give for establishing a good relationship with your attending and team and put them to you first.

This is a great question. I'm going to kind of divide it up into when we had rotations in person and when we have rotations virtually, um when you are have inperson rotations, I think the best thing to do is to introduce yourself to the entire team and the entire team is not just the physicians and the residents, but it encompasses the nurses, the techs and everybody on your team, get to know them, get a good relationship with them, introduce yourself, know their names and ask how you can help them.

And that's very important. They're gonna remember you because they're gonna remember that one medical student who was very helpful, asked how you can help our patients, how we can help our staff when we're doing this virtually.

That's a very important question as well. How do you establish a good relationship virtually with your attending the residents and the fellows?

And I think it's to be alert during the webinars, we wanna make sure that you are paying attention and that you're not looking down.

So make good eye contact virtually as much as possible. And they're interactive lectures.

So ask questions. We love for you guys to, you know, pause us and ask questions because we're here to teach.

We want to be able to answer the questions you have on the other side of the screen. Oh, great suggestions.

P uh I think Roger is second for this one. Yeah.

II really like pm's answer. That's really um great, especially for this COVID world when we're uh on Zoom.

What I, what I thought about when I thought about this question was uh II instantly remember going back to my internal medicine rotation when I was an intern and one night I was just as sick as a dog.

And back in those days, this is before the 80 hour work week, you just worked, right? You, you're sick.

OK. That's fine.

You're, you're still working. So um back then my coin intern we, we split the shift and, and I went to bed.

It was my turn uh for admissions. And uh I didn't get called.

And the next morning we're rounding and we come across this patient and the patient is not my coin interns and I never saw the patient.

And so the senior just starts starts presenting the patient and to the attending. And I'm like, when did this patient come in?

I found out later that the senior didn't wanna wake me up. He knew he was sick and he went down, he admitted the patient, even though it wasn't his job, it was my job to do it just, he just felt bad because I was sick.

And I'll tell you that changed the whole tone. Basically, it's the golden rule.

You do unto others as you would like them to do unto you. If you just remember that uh you now instead of trying to push off work to other people and say, you know, you do this, that's not much.

Now everyone's like, like, hey, can I help you out? Can I help you out?

And that when people see that, that's just like, well, this is a genuine human being and, and now it's, it's not a matter of just trying to push off work.

It's like now we're a team, we're working together and that can really change the dynamic of a team and, and really make people impressed.

Thanks for the anecdote, Roger. Obviously, it impacted, you said this many years later, you still remember it not only applies.

But here's a great example where it, you're, you're connecting humans on the team level as well as the service to your patients.

For sure. Uh Francis, what would you add?

So, um when I was thinking about this question, I was really, you know, something that came to mind and, and um most of my teaching is done in the ambulatory setting.

Um these are typically shorter rotations about four weeks and with didactics really, they only get probably about 12 sessions with a preceptor.

So um with the preceptor and the team in a short, in a short rotation like this, I always um thought of something I learned years ago at a society of Family Medicine, uh teachers of family medicine, which was something called um the, the one minute learner.

Um a lot of you probably have heard of different things and um I tried to say, well, II need to shorten this up, you know, I can't this, it's an hour, it's an hour lecture.

But really what we, my point is is that trying to get um your feet on the ground and off running as soon as you meet your attending, et cetera, it's important to, to just introduce yourself um like, like pun said before.

And um and that eye contact is important and also in addition to that, to set goals with your preceptor, what do I want to see today?

What are my goals for this rotator? What are my particular interest that I would like to, um perhaps see in the next couple of weeks in addition to that, you know, there's just some, it's like, it's like a dance, right?

What I wanna know when, when, um when I need to ask questions, is it at the end of the visit? Is it during the patient encounter this way things flow perfectly as soon as we get started.

So, um you know, really it's like a, it's like a, it's like a symbiotic relationship and everything goes smoothly in these short rotations that I'm accustomed to.

Oh, excellent advice, Francis. I also we use the one minute preceptor, one minute learner at, at, at UCSF as well too.

Um uh Arsen Hi. Um So actually I am a pediatric intensivist, so I do um a lot of inpatient teaching altogether.

So, uh I would, you know, take this uh in a perspective of really in doing inpatient rounds and after going to a rotation, for example, a rotation, uh a clerkship rotation, right?

So the most important thing I always even tell this to our new student. Most important thing is really to introduce yourself as the student doctors to the team, right?

II think that's the most important thing. They know that you're here to learn and then know about what the, what's the objective of this rotation.

So when you're doing actually inpatient, what is my objective of this rotation? Be prepared?

You wanna know, OK, this uh they expect me to gather history and physically do a physical exam. This is my, these are my expectation.

So I want as a student, I think being prepared, we don't expect you to know everything, but I think being prepared uh oo on the task per day, one of the most important thing I always say, know your patient well, right, be sure you examine your patients, be um especially going on into rounds so that you'll know what's going on.

We don't expect you to know the plans and everything, but we want you to know the student, uh your, your, you know, your, your patient um all the phys, all the history and the physical exam altogether.

And also make sure also that you read before that maybe if you know the case that you have reread something before you can ask a question, right?

Make sure that at least you know, all questions are great. II have to say, but I think if you like preread something and you really kind of ask really things that you don't know and be honest that you don't know about it, I think it's a good way to start off with your team.

Right? I think most of the time your residents, your attendings are there to teach you and I, but I think they expect you to also to be a self directed learner.

So I think that's one of the expectation that I want, you know, your, the students when they come to the rotation, such great advice all of you are offering.

It's just we're, um, even though we're all in the same country, um I imagine a lot of this advice is applicable internationally for learners anywhere in the world.

Um, my additional two cents and then there's a question directed to Roger, I'll float to you. Um, I think that it's important to be uh your honest self with uh with your attendings and your faculty and teams.

Like if you know, you wanna be a surgeon, don't lie to me and tell me you wanna be a psychiatrist. I don't need that.

But think to yourself like Arinia said, what do you want to learn on your psychiatry rotation to be the excellent surgeon you intend to be?

So, getting a sense of what your goals are for that rotation is really important. Uh Roger uh first to you and anyone else can chime in um for the MS threes that you recommend really strongly.

Um What did you, what did they do differently from other students? And the same question, everyone else, we have three minutes to answer this Roger first.

Um The ones that are memorable in my mind are the ones that read outside and brought it in with them and showed that they were reading outside.

Uh You know, there's one thing that all of us on the panel can tell, we can tell the students that are just kind of showing up and that's all they're doing.

It's painfully obvious when we can see it. And it's, and we know, so, um, the MS threes that really did well, were the ones that read outside, brought it in with them and applied it to the patients that we had.

Any other panelists wanna chime in any additional advice on that one? Yeah, I can.

So, I think one of the um the MS that stood out, I agree with Roger are the ones that read, asked questions. And for emergency medicine, I think it's really important that there are team players.

We don't work individually in emergency medicine. We really rely on the entire team to, you know, work together.

So it would be, are you able to get along with the residents? Are you establishing a rapport with your residents, with your nurses, with your techs and with your patients?

And even more importantly in emergency medicine is follow up, you know, just, just get the HP and come back to us and then, you know, forget about that patient.

We love it when the students are following up and those are the most memorable students for me is the ones that did follow up that were very proactive with their patients and with their team Francis looked like you were gonna chime in too.

II was so um similar to what was saying things that, that really are memorable for me. Um in, in especially longitudinal rotations that I have now or even short rotations are students that um that really care and uh care about the patients that they see with me.

So for example, I'll um I'll, I'll see a patient with uh with pneumonia, let's say, and treated in the outpatient setting.

Um The student comes back and said, hey, um what happened to that patient before? Did they get better?

Did they come, did they come back for their repeat chest X ray? And we can discuss this and we can talk about medications and prevention and things and, um, of, of disease further, um, uh, for, for that patient.

So it's, it, it's really when, um, when they take ownership of patients, I guess is, is really what's most impressive to me as we move on to the next question, I'll just summarize, notice that all this advice is, um, for F or sp specialty agnostic, meaning all of the supplies regardless of inpatient outpatient E RPI C, et cetera.

All right. Next question.

How can nerve do create a lasting impression in a short time in Roger to? Yes.

All right. So, can you hear me?

OK. All right.

So, um, actually, I think Arsen answer to the last question was the best, uh, was the best answer to this question. So I can tell you my own experience when I was a third year medical student and we had a pneumonia patient.

I went out and did some outside. And I remember from physical diagnosis class that one of the signs of consolidation was whispered pectoriloquy.

And if you don't know what whispered pectoriloquy is, that's the whole point, whispered pectoriloquy is when you put a stethoscope on someone's back and they whisper and it's louder than it would normally be.

And that's because the consolidation amplifies that. Well, on rounds, I put in my physical exam that the patient was positive for a whispered peil and it raised eyebrows and, and I'll tell you why that was a lasting impression because when I got my dean's letter, two years later, they put all the comments in there, all the summative and cumulative comments from my uh attendings on that rotation.

And sure enough there, it was Roger was one of the few students in my life that has ever uh mentioned about whispered pectoriloquy and that and that sort of carried it along.

So it goes right back to what sin was saying is go do outside reading. But the second point is is that show that you've done that outside reading on rounds and incorporate that knowledge into the patients that you're actually seeing uh Arinia.

What would you add? Well, I would add, actually, actually, that was great.

II II, it's kind of hard. II actually also was a nervous student when I started my, you know, my my clerkship rotation.

It's kind of nerve bracing, especially if you don't know anything as I said before, you should read before, I think one of the things that you want as a nervous students is to that is really have a plan, right?

Know what you wanna learn that at the time have, for example, like for example, even one patient, you should at least come up by reading through and knowing your patient have something to uh a plan for your patient even though sometimes it will not be a good plan.

So, but you have suggested something. So if you have a, at least you're attending, see you that.

Oh, I was, he was able to at least come up with something that he wants to do for the patient and be reliable. I think reliability and trustworthiness is very important because if you can show us that you are reliable, then you, I can give you more responsibility as you go through your, you know, your, your uh collect really great advice.

I'll second your reliability. It's more about your commitment and less about your knowledge.

That's why we're teaching you. So you can learn more.

Uh pem. Um I first like to start off by saying that it is totally normal to be nervous.

So don't be hard on yourself. We're all nervous when we start something new and we're all nervous when we have to impress somebody.

So I think just knowing that will make you feel bad that it's ok to be nervous. And let me tell you that your residents that are on your team, your fellows that are on your team, your attending that is on your team.

We're all nervous when we start something new. So we've all been through your shoes like we were in your shoes a few years ago, 10 years ago.

What not. So we understand how you feel and once you understand that, I think the rest of it will be a little easier.

Another um thing that you guys can do if you're nervous is always gather your thoughts before you speak. Sometimes when we get nervous, we tend to ramble, we tend to speak very fast.

We tend not to be very clear. So I think that if you are nervous, you know this about yourself before you present, before you ask a question before you approach, you're attending the residence of fellows, gather yourself, gather your thoughts, have a plan and then go present and once you have a plan, you're much more confident because you know what you're gonna talk about, but don't just go up there and start speaking because that's when you'll get scared, you'll get nervous and you won't be your best self when you're with your attendings and your um residents and fellows.

One other thing that I can add, we have a student clerkship director and I'd say if you are somebody who is nervous and you may forget somebody's name before you go on to your shift before you start the rotation, email your student clerkship director, they're there for you.

Ask him, everybody's name, ask him who's, you know, on your team with you. And once you just get through the basics, it'll be much better for you on the rotation.

Uh The succinct way I've heard. What you just said was uh if you fail to plan, then you plan to fail.

Uh Francis, what else would you have? Sure.

I mean, those are, it's hard to go last after such such such great answers. Um I, everything every e everybody said was on was, was really what was on my mind?

Um If I could summarize really, I would say just read, be prepared. Um and, and be prepared and focus and if you are nervous again, like ours and other people, um I, I'm nervous.

II was I still get nervous and it's a normal natural response. And um what I do, I practice, you know, I practice and I'll practice uh presenting pa, you know, if I, if I have to present to patients, I'll, I'll practice.

If I have to give a talk, I'll practice and that, you know, will, will really boost my confidence, make me feel a lot more comfortable when it's time to time to shine, right?

So, uh just because uh others have shared anecdotes from our own sort of early days when I was a first year attending, I worked in a psych emergency services and I um and there was a patient who had impulsively attempted suicide immediately called 911.

We pumped his stomach. He was totally medically cleared.

He had an outpatient psychiatrist appointment scheduled for tomorrow and that medical, er, had cleared him medically and they asked me to see him and I was all nervous about whether it was safe to discharge him.

And the other attending looked at me as an attending and he got, you're, you're a first year attending, aren't you? Because I was so nervous as an attending.

So acknowledging, we're all nervous. Uh but um the, the advice you've heard from the Panelist is really beneficial to help you work through that anxiety so you can do your best.

Let's move on to the next question. We're gonna uh offer advice to how to ask for as students for evaluations or letters of reference.

This could be either or both in Francis Europe first this time. Sure.

Um Thought about this a bit and really what uh what it came down for at at least um because for our students going into family medicine, II had asked for a lot of letters of recommendation.

And the one thing that I would do is I recommend um number one, ask for that letter um in person, right? So I always say, ask for that letter in person and, and also um start your rotations but also during your rotation near in midpoint or at the end, make sure you tell your attending that um at some point, um I'm gonna ask you for a letter of recommendation.

In addition to that, I always like a personal statement. I like a CV as well.

And in addition to that, get to know your preceptor. Ok?

Um It's not just about medicine, it's about what your goals are, what you do on your free time, what you do as far as um service learning and um and, and um what uh what different goals and aspirations you may have that helps us really focus and write you a good letter of recommendation.

Thanks. Uh Put him your second in terms of um I'm again, gonna divide it up into two parts.

I'm gonna divide it up to where we have inperson rotations and virtual rotations because I know with virtual rotations it's gonna be a little more difficult.

Um So when we're asking for letters of recommendations, try to get a evaluation of mid rotation and I think that'll help guide you for the rest of the rotation.

So mid rotation, if you think you wanna wanna ask this particular attending for a lot of recommendation, the first step would be talk to your student clerkship director.

They're the ones who are gonna be managing the entire lot of recommendations with emergency medicine. It's a little different than what it's gonna be with all the other rotations.

So I'm just gonna speak generally mid rotation. As for an evaluation, they'll give you feedback and they wanna see that you worked on the feedback.

We all are learning, you know, we even as attendings are learning. So as a student, you are there to learn, they're gonna give you feedback and the attending would be thrilled to write a lot of recommendations for somebody who they saw worked on the feedback and they took the feedback very well.

And that's a very important quality as a student, as a resident that they wanna see in their program. Now, when everything is virtually, how do you ask for a lot of recommendation?

It becomes a little more difficult. They, you know, they didn't see you go talk to the patient, they didn't see you um get that history and physical, they didn't see you interact with the nurses and everybody else.

So I think when it comes to a lot of recommendation, virtually, again, your student clerkship director is going to be a go to person with us.

We have Doctor Anita Louis. She's great when it comes to all these questions and helping you navigate this um pandemic actually.

And for just virtual rotations, when it comes to asking for it, virtually, make sure that you are interacting with those attendings when you have these live webinars.

And when you do click with an attending, email them at the end, ask for it obviously in person, which virtual will be very hard.

But when you're emailing them summarize what you like to about their presentation. Summarize some important key points where they can remember you by, you know.

Oh, yeah, that question that I asked, I loved your response to it or I went back and looked up the topic, make sure that you are very interactive instead of just asking for a lot of recommendations, summarize their memories of you, summarize important points um for them in the email when you're asking, we're doing great on time.

So our senior feel free to expand just like uh two previous panelists have. I know.

Uh Thank you. So this seems to be very obvious, but I think you should really make sure that um you choose the person who's gonna write your letter uh in the same specialty that you want to actually match in a residency, right?

That's very important because I think that carries more a lot of weight, especially for those, your, your, the program director of the residency that you are actually uh somebody who's, you know, in pediatrics or internal medicine that you're going through.

Uh make sure that they write this. And I think one of the most important things, especially if you're aiming to go into internal medicine, right during the clerkship rotation, make sure you identify the person that you wanna write letters with the you altogether.

Although you're gonna work with a lot of the attendees, but know the person that you're gonna be working a lot and meet with this person altogether and say to you, this is like what I want to do in life and you know, you always ask them advice or why did you pick internal medicine?

Let me know, you know what you think about it. This is how I feel about the, the specialty.

And also te tell them your aspiration that you wanna be an internist, right? And also make sure that you work with them.

And actually, as doctor, um I said, you know, maybe do that during the mid clerkship and kind of take a look at what your evaluation and uh your assessment from them altogether.

So I think that's the most important thing, although you sometimes you wanna ask a lot of other people that has high higher position to write you letters.

But I think the person from the same specialty that you're actually applying carries more weight than all those other like assistant dean or anybody that's gonna write you a letter.

Thanks Roger. OK.

So if you are like me, somebody who is terrible with names, terrible, although I can remember a face for years. Uh And if you cannot for some reason, get the letter request out during the rotation, what's gonna happen is you're gonna ask for a letter from an attending months ago who if they're like me aren't gonna remember who you are.

So if that's the case cause II teach pa students and sometimes they ask me for letters of recommendation like up to a year later because they're going into uh they, they need to get a job at a hospital.

They need a letter of recommendation, et cetera. Please send a picture because if they're like me, they'll remember exactly what happened on the rotation as soon as they see your face.

Uh that could be a good thing or it could be a bad thing. Uh But if it's obviously if you're asking for a letter of recommendation, you're hoping that um that it was a good experience that you had send a picture along if it's an email or if it's a letter.

So they say, hey, remember me, we had great times, we did this and remember this patient that we had that's gonna jog their memory.

You're gonna get a much better letter. If that's the, if that's the case better than that though is to get the letter there while the iron's hot, I'll add two additional thoughts to what you all added.

Um First one, give them an easy out if they're busy at a time in their life when there's other stuff going on or they've got personal health issues or who knows what attendings are humans too, right?

So, um give them an easy out by saying if you're too busy right now, I understand or if you're unable to write the letter, I understand.

And that gives them the face saving way to say I can't write you a strong letter of recommendation now and better for them to say I can't write it earlier so you can get someone else to write you.

One. Um, the other piece.

II agree with what Arsenio said about it. You must have a letter from someone in the specialty that you're applying into.

In addition to that I think, think about the package of letters that you will have in your package. And if you, if you can have a diversity of voices that complement each other about different aspects of who you are as a person and a future physician.

So you may well have someone in the specialty that's not the one you're applying in, but they really saw your human bedside manner and the connection with patients and they can write about that regardless of whether it's your specialty that you're applying into.

So think about the package of your letters and try to have a well balanced package. Um, looking to see if we have any other questions about this.

Um One question just came up, is there such a thing as asking for a letter of recommendation too early? For example, in terms of years before you actually go into the residency, um I'll just open it up for any of the panelists to answer that question.

Um I think I, I'd like to comment on that and, um, you know, again, like Arinia and some of the panel um has said that it's, it's always, it's always important in that specialty that you're, that you're going into.

Um, we wanna keep that in mind now. Um, I don't think y I, you know, years seems a little extreme.

Um, you know, uh, and I'm so if you're in a, if you're in a clerkship in your third year, um, we do as, as someone that writes a lot of letters, I wanna know that student, but at the same time I also look for other opportunities to work with that student.

So that, so that um I have a, I have a, a longer span of time. I've known them.

Um for example, I run a student run free clinic, so I'll have them volunteer there in addition to the rotation they were in with me.

Um This way, I get a more rounded picture of that student. So again, back to the question is it, I think it's better to have a stronger letter.

Um when that attending knows you rather than a weaker letter. When um when like Roger said, they, they don't even, you know, they don't even remember your uh your name, but they, they might remember your face, but you don't want some random letter just to get something out.

So, um again, that's, that's my opinion. At least a great advice uh Po Roger or send you anything.

Uh Well, II have to say though, um the uh the program director knows whether your letter writer they're very good in spotting this, whether your letter writer knows you really or just kind of write you a general letter, right?

So if somebody doesn't know you well, they would write you a general letter just saying, you know, you rotated it and this is what you did and altogether.

But if the person knows you the best, I have to say they can write a lot of like tidbits of what, you know, the teaching moments with you and how you do very well with patients altogether.

So that makes a lot of difference. So I think it's very, you know, I think I know that maybe one year is too much to you to say, but at least for one, that person that you work with, uh, you know, maybe I'm gonna ask you uh, to write me a letter but it depends on your availability and I'm gonna email you once the, er, uh, the IRS opened up, you know.

So I think that's a good way to, to tell the person that you want to, you work with a lot and that basically can write you a good letter.

Um, one final follow up on this, maybe p if you don't mind answering, I'm just picking you at random. Um, some questions from our uh international medical graduates about applying from, if they're applying to the United States and, or if they're applying uh in multiple specialties in those special case scenarios, any, any quick answers or thoughts on those.

Uh I think that it's good to be honest with the pro with your program, directing the programs that you are applying to multiple specialties.

I think that that's one thing that you would keep in mind and I'm not really sure what the exact um, co focus of the question is, but if you're applying to multiple specialties, it's ok.

We all know that people have to do that and don't just be honest and genuine about it. We may get to some more of these questions that are coming in about residency applications and letters at the end.

But let me move us ahead. Oh, here we go.

Um Here's your free text, answer, an opportunity to reflect on any other tips you'd offer uh cross all the topics that we talked about and and you happen to be first for this one, please.

Great. Um I have a few tips that um I'd like to share.

I think I said this earlier is you always wanna gather your thoughts before you present. Remember your attending, your residents are very busy.

They um sometimes or life and death situations especially in emergency medicine. So when you do speak to them, when you are presenting, gather your thoughts, uh number two would be ask a thoughtful questions so that they can remember you later on.

So you wanna make sure that it's gonna be quantity, quality over quantity. You don't wanna bombard them with 100 questions because you're trying to impress your attending.

You can ask a few questions, just make sure that the quality of questions is genuine to, you know, you don't wanna just ask to ask, you, wanna ask a question that's gonna enhance your learning cause that's what we're here for.

Another um helpful tip will be ask what you can do to help. You know, a lot of times at the hospital things are just very crazy sometimes.

So if you can go and give the patient a pillow or if you can go and ask how their pain is right now, it it really helps the entire team.

And again, we remember the students who were very helpful and who made our shift a little easier. Um Another point is to give them a reason to remember you.

So maybe you asked to, you know, help with suturing, you asked to help with um uh you know, helping the patients fill out their medication form.

You know, these are just little things that we remember you by and when we are writing that letter of recommendation that will come up and we'll be, you know, sure to add that to your letter of recommendation because you don't want a generic or a letter of recommendation.

You want one that has important memories of you and important tidbits for the program directors to get to know you a little better.

Um and also clearly define why you're there. And I think somebody else on the panel said that like if you're not interested in emergency medicine or if you're debating between emergency medicine, make that known, so that we are also, you know, on the same page as you.

And we're totally ok with that as well. And I think those are my few tidbits to offer and you're more than welcome to ask the questions over there or you could, you know, email us as well.

Thank you so much and we will have time for Q and A and I'll, I'll queue them up for you. Uh Arsen, you're next.

So I think the most important thing is that, you know, as a, you know, during your clerkship, it'll be rotating in different rotation.

And I think the most important thing to remember is that no matter whether you're gonna like pediatrics or you, you're gonna go into internal medicine, you have to actually kind of think about what are the things I could get from this rotation to make me a better doctor, right?

I mean, it's very important. What could I get from this rotation to, to enhance my communication skills?

What are the things that I can get from this patient that I could deliver patient centered care? So that's really very important for you to think about.

It's not because you, you do, you plan to go into surgery, you will not be thinking about the other aspect of uh other aspect of medicine.

I think you have to come to a rotation with an open mind and say, I ha I wanna learn something from this rotation and I wanna get it to help me to become a better doctor.

I think that's uh that's the most important thing. And I think the second thing is that, you know, be a team player, be a team player.

I think that's what we really want you because as I said before, in medicine, it's not you alone, you work with different team people.

And actually there should not, there's no such thing as hierarchy. That's what I feel right now.

And I think you should uh actually kind of really like honor what or listen to what other people are saying. Actually, that's gonna make you a be, you know, a better doctor and get a better perspective altogether.

Fantastic advice. Um Francis, great.

So um again, a number of great, great suggestions, et cetera and tips from uh doctor design doctor. And I'm just gonna piggy back a little bit on what they had said, especially Doctor Desi in regards to quality, right?

So what I had in mind for the answer to this was really, it's about Q yes quality but focus, focus, focus right? Often that what we do is we think like um and we get overwhelmed and we think if I'm on my, on this rotation, if I'm in this particular clerkship, I got to learn everything today.

Well, that's gonna get a little overwhelming, be focused. I mean, I know we do, we have different patients that we see but be focused in what you want.

And I think that's the general trend, um, right now here and, and what we've done over the last few minutes or last 2030 minutes is, is, is befo and, and, and have those particular questions that will make lasting impressions.

And we do that when we're really, when we're focused and we have, when we're goal oriented. And I think that's gonna be um one of the most important things to remember.

Um And uh sometimes too much is, is, is just too much, right? And uh my last bit is uh on your clerkships.

Be nice to your nurses. They're gonna take you a long way.

Uh Roger. Well, that's, that's exa that's amazing advice.

My mom's a nurse. She told me that all the time in med school, it's like whatever you do be nice to the nurses they can make or break you.

But, you know, um look, I look at it this way. The first two years of medical school, your success was based on how well you could listen to someone talk and fill in some bubbles on a test.

At least when I was in med school, I was filling in bubbles on a piece of paper. Um Total paradigm shift in the 3rd and 4th year of medical school.

So who are the people that do well in 3rd and 4th years, not necessarily those that do well. In the 1st and 2nd years, the ones that do well in the 3rd and 4th years are the ones that are compassionate, competent people who really are interested, interested in the field that they're going into.

Why? Because these are the people that get up early in the morning and get in there, they read because they're actually interested in what they're doing.

They go the extra mile, they wanna help. So the way the beha all those behaviors that are gonna help you as, as spinal tips are all of those things that people who are compassionate, competent and interested in what they're doing.

So if you think you're gonna be having trouble with that, try to pretend that you're compassionate competent and really interested on the rotation that you're on and all of those behaviors that go along with that are going to sail you into the next rotation.

Uh There's a, a paraphrase of what you just said about like authenticity is everything. If you can fake that you've got it made and joking aside, of course.

Um uh I do, I do want to encourage you all to sort of be true to your hearts and who you are as a future physician. Um We need a compassionate physicians to be, love their specialty area and love what they do and that's how we will all shine in our, in our a areas of cho chosen areas of, of medicine and health care.

Um OK, so I'm, I've uh with special thanks to my teammates, Fergus and Megan who have been as osmosis teammates who have been queuing up the questions.

I'm now just gonna read a few of those and we'll feel free to pass as a Panelist. If you don't wanna answer, we'll just, we'll go in the order on this slide.

Uh Francis Roger and put them for each of the questions. But again, feel free to just pass if you don't have anything to add.

Um uh One of our uh participants wants to know about like, what do you do if you've been out of school for a long time or another question that's related international student who's uh coming uh to do uh rotations, let's say as a subinternship in the United States.

So any advice on either of those domains, let's start with Arsenio. So, um I think the most important thing is before your subi or before you do some kind of internship, maybe you can do.

There are actually hospitals that actually do volunteers where you can volunteer maybe and get like clinical experience from an ambulatory clinic or even in the hospital.

Some hospitals do offer it. I think it's like just getting your um feet wet before you go into um into the clinical or uh uh you know, um going into like a residency or somebody altogether.

Uh I think getting your f we uh you know, make sure that you at least have some volunt uh volunteering, doing and uh volunteering all along and other aspects so that you can at least get a grasp of how to start your clinical care again.

Francis, anything that, um, I think just uh um uh just a little to add for international medical graduates like myself. Um, I think it's really, it's really important to, again, I it's a, it's a common theme with me but be, be focused especially and I could, I could, I could say this for family medicine is, is that um our, our competitive program, our pro our program directors wanna know what you are.

We wanna know that you are family medicine all the way from the beginning. We don't, we really don't wanna know that um you're, you're relying on us as a backup or you're splitting us or you're doing something like that.

We understand you have to do sometimes what you wanna do, but we want dedication and um again, like Roger was, was saying in regards to, you know, we don't want someone faking that they wanna be a family doctor and we want a compassionate doc and you know, and this is part of medicine.

So um it's something that you really have to think about when you're uh when you're applying. I know that wasn't the question.

It was a previous question, but I did wanna address that. No for sure.

Thank you. All.

All advice is excellent advice. So, uh Roger anything to contribute on this one?

Yeah, the only other thing there is research I've seen, uh I've actually worked with a lot of four medical grads. Um and they were trying to get into residency programs and what they did in the meantime was they did research and they worked in those fields that they needed to get letters of recommendation from.

You know, it, it goes down to the old adage. It's not all what you know, it's who you know, and that's not a bad thing because when people get to know you, they know who you are and that's important.

Pem. Um I'm gonna second that was for Roger.

Um I work me many um foreign graduates who are waiting to get into residency. And in the meantime, they joined our research team at our hospital and I think that's a great way to get to know the attendings, get to know the program and do something meaningful with your time off.

Got it. OK.

Um uh Let's uh I think time for one more. This might be a little long one.

So it's OK if your answers are a little long. Um But consider this your last utterance so you can end with a bang for each of them.

So um and this has to do with getting the same educational clinical experience via webinar or zoom versus interacting with patients.

Now, I'll just amend the student's question. It's not the same.

Of course, it's not the same, it cannot be the same. So how do we maximize the educational value or yield of zoom based clinical experiences?

Um And um we'll go in order again, Arsen, you're first. So I think um one of the things that we have been doing now is called telemedicine, right?

So telemedicine is really one of the good aspect of what happened in COVID, right? So you can do both telemedicine and ambulatory care and you could also do telemedicine even in inpatient, right?

So these are the things that you can actually do to optimize. Um you know, one of the things that you could do for your learning.

Um remember even the student, right? Even if there's another surge, I don't know what will happen to our student.

However, we can actually go through this mode altogether because the resident will still stay there and you could uh ask your faculty and your attending to let you join on round by doing this telemedicine altogether.

And the other aspect is really, you know, what one of the things is that simulation, right? There are things that we can do in simulation, that you can do it even in zoom.

And there's a lot of like website that are offering this actually, even the simulation for healthcare. They have a lot of resources that you can do this um in simulation uh on behalf of the whole osmosis team.

Thank you for joining us on the panel, Francis. So um to piggyback off Arsenio, we come from the same institution we dealt with the same COVID related issues.

So, um like I said earlier, um we took advantage of telemedicine and um what we did is we have a, we have a network of standardized patients that we use in our um in our simulation center.

So what I did was I did a series and I A Zoom or the Webex series um with our students in regards to how to perform a um an examination, a history, a physical et cetera on with via telemedicine.

And then we set them up with patient visits. Um They can, they can be, they were observed and they were taped and then we can, I gave them active feedback um as well as feedback from, from the preceptor.

In addition to that um you know, things may be difficult, but in our practice of medicine course, some things that we did were were that um during uh when we taught to not myself, but uh a colleague of mine taught the musculoskeletal and um and a and a neuro exam, it was a little challenging than, than perhaps an he ent exam, right?

So, what we did was um he, we, we made sure that um they had a family member that they were living with that was around that they could via Zoom show and, and, and, and perform examinations and our preceptors could actually watch them doing physical examination.

Um, it got challenging because, um, out of all our students, there were a few that actually couldn't find somebody et cetera, but that's not the point here.

Um, the point is is that it can be done and there's some quality education that we can do via Zoom um webex and, uh, virtually that is on behalf of the whole uh listening audience.

Thank you, Francis for being on the panel, Roger. Yeah, I mean, if you just listen to what sin and Francis just said, I think you've got the whole package there.

If you think about it, we were just thinking that Zoom meetings were such a, a poor shadow of real medicine. But as it turns out medicine is turning into zoom meetings, uh we, you know, our, our scene is right, we are doing telemedicine in the ICU, we're doing telemedicine all over the place.

And so the irony is is that is actually that is becoming what medicine is like. Um But then the flip side of that is that when you're stuck in front of a computer, doing a, a Zoom meeting, you know, trying to make it more real is exactly what Francis talked about is actually practicing what you're learning there on the other half of that Zoom meeting with somebody who's there in real life who you don't have to be distant with.

And and obviously that can't always be the case, but it can be the case if you choose to have it. That way.

The other thing to think about is, is exactly what we're doing in telemedicine is when I'm in front of a computer. And I'm looking at the patient, I'm trying to visualize myself being there and, and thinking about what the things I would be looking at, looking at the screen, looking at the vital signs, trying to examine the patient.

And I think that's AAA useful tool to use when you're learning via zoom is to visualize in your mind as if you were there on the other side of that camera and that's gonna increase your interest, it's gonna keep your attention so that you get the maximal effect of that zoom meeting.

Thanks Roger for all your wisdom and advice. Poonam.

We give you the last word. I think that I alluded to this before um try to pick a rotation where they are actually going out of their way to enhance your experience and enhance your learning experience.

I think that's very important. Um And I only know this because I've seen how much my faculty ha and how much effort they put in into putting their rotation together, which is again to try to get your especially for emergency medicine because a lot of what we want to teach is procedures and that's, you know, exciting and that's something that we all wanna learn about and how do you teach procedures?

How do you teach all that while you're on a zoom on the other side? And what we've done is we've done our best to create these inperson lectures to take you into our simulation lab and do it live where you can ask questions.

Um and more importantly, where you have fellows residents and everybody teaching. So I think that's really important is that when you are picking these rotations, try to pick institutions that have gone out of their way to create this learning experience because we're all learning right now.

This the pandemic and everything is, is very, very new. So we're learning and, and feel free to give feedback to the programs that you want to, you know, rotate through the be, hey, can you help me enhance my experience?

And I think that's very valuable and we all wanna hear how we can help you again. Thank you on behalf of everybody.

I will just reflect. I don't know if I have last slide with my teammates.

Let's see. I think that's the last slide I'll close just by saying it took a global pandemic to bring us all together like this across the the world with students.

As you all saw on the chat from dozens of countries, at least on the other hand, um you know, there's a osmosis image that says we're all in this together and you got the osmosis azzie bot hugging the whole world.

We really are all in this together. And so I'm deeply grateful for all of your wisdom and for all of our participants today.

Um Thanks everybody. Be safe.

Continue to do what you need to do to mitigate this virus so we can all be the docs that we need to in this world and other health providers.

Ok. Thanks everyone.

Have a good rest of your days.