U. S. clinical experience (USCE) includes many types of clinical rotations and observerships. They can be grouped by residency type much like the shelf and board exams. They can also be classified more traditionally as medical vs surgical. For medical students and international medical graduates (IMGs), the easiest way to conceptualize the different specialties is often by core and elective rotations. These distinctions are explained in greater detail in the Medical Student Guide to Clinical Rotations & Clerkships.
However, many sites are limited in availability or very competitive such as sub-specialty externships. We will focus on the types of rotations you are most likely to encounter during your medical school rotations. Here are answers to the most frequently questioned topics regarding clinical education and best practices while on the wards.
Planning for U.S. Clinical Experience
Like everything in medical education (and life) proper preparation prevents poor performance! Preparing for your clerkships may consist of researching material to utilize during the rotation, reaching out to your preceptor ahead of time, and scheduling your personal and study time. You will need to master your clinical experience schedule, personal life, and preparing for the USMLE/COMLEX board exams and NBME/NBOME shelf exams. If you have resources available through your school, that is a great starting point. However, resources can change frequently so make sure to keep updated with current materials.
Of course, every medical learner will need study materials (books, videos, lecture notes), testing materials (qbanks, chapter reviews), and review materials (flashcards, spaced-repetition software). Spacing out your resources and varying materials is the only efficient way to study to the high degree of quality that you will need to perform your professional tasks. If you would like the science behind some of these techniques, see the resources below.
The exact book, video series, or other materials you use will depend on the individual and can vary greatly over time and subject matter. You are already familiar with the resources your fellow classmates have used or that you have used in the past. Instead of a “resource review,” we will focus more on expectations for the first day of your clerkship, how to set and reach our goals, and how to make the most out of each clinical experience.
Based on physician interviews, we also recommend personal development materials that are less commonly discussed in medical student resources. These skills include personal finance and business, leadership development, interpersonal skills, increasing emotional intelligence, and self-care (meditation, gratitude practice, fitness). Many medical students are high IQ individuals so finding ways to separate yourself from your peers will stand out when applying to residency and for patient care!
Here are the most universal core rotations. However, there are variations from school to school. Some top-tier schools do not have family medicine in their core curriculum, while other schools add neurology, emergency medicine, or other alternatives into their curriculum. However, these are the most common and likely most important to know for your shelf exams and board exams.
How to Prepare for Family Medicine Rotations & Shelf Exams
Family medicine is a relatively new practice, becoming a specialty in 1969 when the need for more personalized patient care was sought. It is one of the most variable specialties, allowing for both inpatient and outpatient settings, performing of patient procedures and labs, and family care from pediatrics to geriatrics. Due to this diversity, it is also difficult to know how to best prepare for both your clinical education and your academic studies for the family medicine shelf exam.
Make sure to understand your preceptor’s expectations on or before the first day of your rotation. Some may require special attention to daily tasks, while others may allow for more personal downtime and studying during rounds. Some will offer materials to study from while others may prefer face-to-face instruction with their students. It’s always important to know the preceptor’s expectations and to share your own with your clinical educator. If a Letter of Recommendation is sought, let them know and ask how you can stand out during your externship.
If your family medicine clerkship is in the hospitalist setting, you can expect to complete early rounds and have a relatively full list of patients each day. Most medical students are going to either follow their preceptor through the wards. Some may complete the history and physical (H&P) and report their findings prior to the physician seeing the patient. These rotations can be one-on-one with the preceptor or with a group of residents, medical students, and even pre-meds following the same attending.
When in the community-based clinic setting, a medical learner is likely to have much more interaction with their preceptor and the patients they care for. This can be in a private practice setting, urgent care, direct primary care, or several other clinical environments. Though still fast-paced, there is often less urgency or concern about serious ailments in these settings. However, that doesn’t mean one should let their guard down! Emergency department visits often begin with what is found during the clinical exam.
As for your continuing education, the family medicine shelf exam can be very difficult to study from. It offers a wide range of patient types, ages, and clinical settings just like in real life. Many USMLE/COMLEX study materials also do not have robust sections for family medicine. Due to the versatility of the specialty, it is sometimes recommended that students leave this until later in their academic year if possible. This allows them to gain experience in other areas that may overlap with clinical knowledge and family medicine experience.
How to Survive U.S. Clinical Experience: Internal Medicine
Internist generalists are focused on the care of adult patients and on all organ systems. In fact, the specialty is so vast that many resources still refer to IM simply as “medicine.” Internist specialists are concerned with a particular organ system (cardiology, renal, respiratory, etc.) and generally complete a fellowship in internal medicine to become specialists.
It is most common for medical students to have a hospitalist internist during their clerkships. However, internists may also practice in a community or private clinic setting as well. Many of the same rules apply as described in the family medicine section above. Make sure you have a clear understanding of all academic and personal expectations from your preceptor and share your own as well. Also, clarify any desire for an LoR in advance and ask the requirements for a “strong letter.”
The clinical setting, private or hospital, may be comparable to family medicine in terms of time and the average number of patients you will see per day. It may also have a similar variation in the number of students rotating simultaneously with that preceptor. The main difference is in the patient population.
Unlike family medicine, internists do not treat the pediatric population, which is an important difference. Internal medicine practitioners are also often the next stage in a patient’s journey when preventative FM care and non-interventional treatments have failed. This patient population may require more urgent care and a step-up in treatment options.
For your shelf exams and board prep, internal medicine can be a beast! It is not separated into generalists and specialists and often makes up anywhere from 60-80% of review book and qbank material.
How to Master Your Pediatric Clinical Experience
Pediatrics is an interesting specialty and unique clerkship. Students may consider this the “internal medicine” of the peds population. If you have read the above sections, you will note that both family medicine and internal medicine can practice as a hospitalist or in the community and private practice settings. The main difference between pediatrics and internal medicine is that IM practitioners do not treat the pediatric population. This is where peds practitioners come in!
The same rules apply as above so we will not waste your time covering the clinical environment, setting expectations, or requesting a Letter of Recommendation again. Instead, let us focus on the differences you can prepare for. Namely, you are usually dealing with a population that may not be able to speak yet, has hostile parents, or misinformation guides the treatment of your patient.
First, it’s important to understand that parents, even the hostile ones, are often in a state of fear when entering the hospital or clinic with their children. It may be difficult for those new to the clinical setting to know what to do in stressful situations, or how to respond appropriately to certain questions. That’s perfectly normal! However, you can take some steps towards self-development and better patient care. Here are some good rules to follow:
Remember, “We have two ears and one mouth so that we can listen twice as much as we speak.” Understanding your patient’s, or their parent’s, concerns and empathizing with the situation is a great way to build a relationship with all parties involved.
As for board preparation and the pediatrics shelf exam, you will want to focus on one specialty-specific review book (NMS, Case Files) and the relevant section in any board review book and qbank you are using. Peds questions are difficult in that there are many genetic diseases that are unique to this population as it is when they are discovered. However, they are also quite rare, and it’s unlikely you will never see them outside of the textbook.
It can be difficult to remember all of them during your brief pediatric clerkship. Consider using medical mnemonic strategies to make it more interesting while studying. We also recommend this strategy for the complex developmental milestones chart and the pediatric vaccine schedule. Choose some key differences that stand out to you and memorize those. It’s much easier than remembering the entire chart! These topics will show up, but unlikely to be high yield enough for the amount of time it takes to memorize all of the information.
How to Succeed on Your OBGYN Rotation
Most of your clinical experience will be in the outpatient environment. It will consist of frequent pregnancy check-ups, STI checks, and general female and gynecologic exams. Your patient population can consist of all age groups. You may even see pediatrics from time to time for unusual presentations where the guardian decided not to take them to their family physician.
You may also see transgender, non-binary, and other LGBTQ patients so make sure to review proper terminology and special considerations with your preceptor ahead of time. You are not expected to be perfect and all-knowing. You ARE expected to be considerate and respectful of each and every patient.
For the surgical side of obstetrics and gynecology clerkships, there are a few procedures you are likely to see and should be aware of. There are innumerous rare procedures as well but we will not go into great detail about those.
During the obstetric-gynecological clerkships, a learner is likely to see both the inpatient population and the operating room environment. It is one of the few specialties offering this diverse blend of primary, neonatal, and surgical experience. The versatility is one of the most commonly stated reasons physicians choose an OB/GYN residency.
Besides the information provided above, you have to prepare yourself mentally and emotionally for one of the most intra- and inter-personal physician-patient experiences (or student-patient) you will receive. This can be very uncomfortable for students at first. That is nothing to be ashamed of. It is important to clarify any discomfort and questions with your preceptor as early as possible.
You may also turn to other students and staff for advice if you are still unsure. The number one rule is to always be respectful and professional, even more so than you might need to on other clerkships. Medical learners are in clinical scenarios where the patient may be in a particularly vulnerable position, both physically and emotionally. Treat each patient as you would your (enter your favorite and most respected individual here!).
Most of your clinical experience will likely be outpatient. It will consist of frequent pregnancy check-ups, STI checks, and general female and gynecologic exams. Your patient population can consist of all age groups. You may even see pediatrics from time to time for unusual presentations as an alternative to their family physician.
You may also see transgender, non-binary, and other LGBTQ patients. Be sure to review proper terminology and special considerations with your preceptor in advance. You are not expected to be perfect and all-knowing. You ARE expected to be considerate and respectful of each and every patient.
- For gynecology, the LEEP (for treatment of HPV/atypical cervical cells) hystero-oophorectomy (or some variation) are quite common. Knowing the side-effects of these procedures can be very helpful clinically and demonstrate your interest in the specialty to your preceptor.
The OB/GYN board and shelf exams are also very complicated to study for. It’s a diverse field and you may have limited time to study. It’s recommended that students use a specialty-specific review book (Blueprints) and finish all of the qbank questions for that topic. Even then, without clinical experience in each illness type and procedure, it is very difficult to conceptualize all of the material you may be quizzed on.
Pay particular attention to USPSTF recommendations regarding female screening and STI screening and prevention. These timelines are very important for any diagnostic or surgical question that may arise. Learn the prenatal checkup recommendations, labor & delivery stages, their warning signs, and treatments. Also, be familiar with STI images, which may show up on exams.
How to Shine on Your Surgery Clinical Clerkships
Traditionally, medicine was often thought of as “medical or surgical.” Although this sentiment is a vast oversimplification, from the point of a medical student on a several-week surgical clerkship this may be a fair assessment. During surgery rotations, medical students can expect to receive a mixture of pre-op outpatient, surgical inpatient, and post-op outpatient experience.
Unless you are seeking residency in cardiothoracic, orthopedic, or another very competitive specialty you will likely stick with general surgery for your externship. Sub-specialties in surgery are particularly difficult to enter into as a medical student due to the limited number of clinical sites. Physicians also often want greater student foundational knowledge in order for a surgical subspecialty clerkship to be effective.
Surgery can be as much an art as it is a science. Those with shaky hands, problems with blood, or lacking physician endurance may find this a difficult profession. However, the medical education aspect of surgery can be quite versatile. Some rotations will be heavy on operating room time while others may be an optional bonus for interested students. It bears repeating, make sure to clarify the preceptor’s expectations as well as your own on day one!
Much of the non-surgical portion of your surgical experience will be seeing patients pre-/post-op. Preoperative assessments are required for all invasive surgeries as well as many non-invasive procedures. Post-op examinations allow the student and physician to assess the healing process, mobility, and general patient quality of life after the procedure or treatment.
The surgery board preparation and shelf exams are quite extensive and can touch on just about any organ system from your internal medicine material. Dr. Pestana’s Surgery Notes has been a classic for years and still acts as a good overview as well as OnlineMedEd. However, the depth you will need on your exams may require a more detailed, specialty-based review book (NMS, Surgery: A Case-Based Clinical Review). You will also want to cover all of the surgical qbank questions and even focus on some of the larger IM qbanks sections (gastrointestinal, renal).
The surgery clinical clerkship is usually longer than many of the other rotations, lasting 8-12 weeks. This, gratefully, will allow you more time to study. However, with the quantity of material and the probability that this will be a completely foreign concept to many students, plan to get a head start if possible. For more information, we again recommend this episode of Rounds to Residency.
How to Prepare for Your Psychiatry Rotations
Psychiatry clerkships will be most medical students first foray into single-system disease and illness specialties. Interestingly, the brain is also one of the only systems that need two separate systems to attempt to understand it (the other being neurology)! Psych focuses on brain disorders that generally have no or only minor accompanying physical presentation.
Mental health is of great importance to everyone in healthcare. One reason is that medical students and physicians having some of the highest rates of mental health concerns compared to the general population. Also, because of the overall social impact it has on our communities. It is estimated that mental illness, disability, and care cost the United States hundreds of billions of dollars each year. Similar statistics are seen in other countries as well.
In preparation for your psychiatry clerkship, one of the most important factors will be the clinical environment. Students may experience in-patient psychiatric facilities, outpatient client care clinics, or the hospitalist setting with its wide array of potential demographics. If you are considering a psychiatry residency, the hospitalist setting would be a preferred clinical setting.
In an outpatient clinic, there are some common disorders a student is likely to see. These include anxiety disorders, mood disorders/depression, controlled schizophrenia, grief, substance abuse disorders, and many others. Outpatient experiences may be closer to the observership type of clinical experience as they usually do not provide as much hands-on experience. See the main Medical Student Guide to Clinical Rotations & Clerkships page for an explanation about the types of USCE.
Psychiatric and behavioral health hospitals can lead to greater exposure to more severe and untreated disorders. Hands-on experience is more likely, including medication dispensing, group sessions, and individual therapy. We could also consider the emergency department psychiatric holding room as a subcategory of this experience, as many are pending a “72-hour hold.”
Hospitalist psychiatrists cover a bit of everything mentioned above. Many hospitals do not have the need for a full-time hospitalist, so the psychiatrist may travel to different locations throughout the day as well as handle emergencies that come into the hospital. There is a lot of diversity from location to location depending on the local demographics and healthcare system.
For the psychiatry section board prep and shelf exams, the material is a little more clear-cut than it was for some of the previous core rotations. Board review material and qbanks will have a clearly defined psychiatry section to review. There are supplemental specialty-specific texts (Lange Q&A Psychiatry, First Aid for the Psychiatry Clerkship) that also come highly recommended.
It may be daunting to look at the comparison charts between all the different mood disorders or to differentiate between the types of anxiety disorders. However, with some spaced-repetition (and maybe medical mnemonics) you can excel in your psych exams! Focus on the durations for diagnosis, diagnostic criteria (SIGECAPS for depression), and of course treatments and side effects. It may not be a bad idea to refresh yourself on any past pharmacology material that you found beneficial.
Planning your Away/Elective Medical Rotations
Away rotations can be in any specialty or subspecialty the medical learner is able to apply for. This may include the most common core rotations listed above, school-specific core rotations (which may include neurology, emergency medicine, radiology, or several others), or even certain types of research-related fields.
Most students are in their fourth year when they begin away rotations. This means that they have probably completed their required shelf exams and even their board exams. Of course, as the requirements are specific to each school – and the NBME/NBOME constantly change the board exam requirements – it is difficult to know where each student lays on the spectrum.
As noted in the above sections, start with clear expectations and goals in mind and clarify these with your preceptor. Use the resources we have mentioned to help you better plan your schedule, find materials needed, and get the most out of your USCE. Also, remember to have fun and absorb whatever you can. This may be the last chance you have to experience this elective or specialty!
Consider out-of-state travel arrangements, costs of living, the time required to be accepted into an away rotation, and transport time between your residence and the clinical location. The financial costs are not usually at the top of many student minds, but planning for less debt is always a bonus. Also, research local social events to stay sane! You likely have a little bit of free time now so pick up a hobby, meet some people outside of the clinic, and enjoy yourself. Next stop, residency!