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Medical Student Forum| Volume 58, ISSUE 4, e215-e222, April 2020

Clerkships in Emergency Medicine

Open AccessPublished:January 05, 2020DOI:https://doi.org/10.1016/j.jemermed.2019.11.024

      Abstract

      Planning for clerkships in emergency medicine (EM) can be stressful, prolonged, and challenging. Therefore, medical students should start planning for them early. In this article, we offer guidance regarding several issues pertinent to the EM clerkship, such as the best time to schedule one (or more) during medical school, the most appropriate institution or program to schedule it, the process of selecting and applying for the clerkship, and the number of EM clerkships to consider. We will explain why an EM clerkship should be scheduled between June and October and the reason that 2 EM clerkships at different sites are sufficient for the majority of students. Additionally, we emphasize that clerkships in emergency departments associated with EM residency programs or with reputations for outstanding student teaching tend to be most beneficial. Above all, students interested in EM should attempt to leave a great impression after completing their clerkships by providing stellar patient care, demonstrating enthusiasm at all times, and maintaining professionalism. In turn, they will gain knowledge and clinical experiences that should prove valuable in their future.

      Keywords

      Introduction

      Emergency medicine (EM) has become one of the most desired specialties in medicine (
      • Rowley B.D.
      • Baldwin D.C.
      • McGuire M.B.
      Selected characteristics of graduate medical education in the United States.
      ). The challenges related to the diversity of patients and acuity of care, in addition to the reasonable predictability and flexibility of the work schedule, make the field attractive to many medical students (
      • Kazzi A.A.
      • Langdorf M.I.
      • Ghadishah D.
      • Handly N.
      Motivations for a career in emergency medicine: a profile of the 1996 US applicant pool.
      ,
      National Resident Matching Program
      Results and Data: 2018 Main Residency Match®.
      ). Despite the increased number of residency positions, EM rotation performance is critical for a successful match, especially because the number of applicants for EM residency positions has increased. Early preparation for EM clerkships; strategic planning for where, how, and when to schedule them; and high-quality mentoring are essential for success (
      • Garmel G.M.
      Mentoring medical students in academic emergency medicine.
      ).

      When Should Students Schedule Their EM Clerkship(s)?

      Scheduling the fourth or final clinical year of medical school depends on many variables. Most students interested in EM residencies schedule clerkships between June and December or January, with the majority of students rotating between June and October prior to entering the residency match.
      When scheduling EM clerkships, several issues must be taken into account. The first is how certain the medical student is about his or her choice of EM as a specialty. This includes the amount of exposure he or she has had to the field in medical school (including exposure as part of surgery or medicine core rotations or required EM clerkships), Emergency Medical Services experience, and previous work in or exposure to an emergency department (ED) (e.g., from a family member in the field). Medical students who are unsure about this challenging and competitive field should schedule an EM rotation early during their final year. By doing this, students can modify their plans to enter a different discipline if they realize that EM is not the right specialty for them and adjust their schedule accordingly. The same recommendation applies if the student is choosing between EM and another specialty, as an early selective, subinternship, or visiting rotations provide the opportunity to compare and contrast the 2 fields (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ,
      • Garmel G.M.
      Getting the most from your emergency medicine student clerkship.
      ).
      Other variables students must take into consideration in terms of their timeline include their competitiveness as applicants, the competitiveness of the EM programs to which they plan to apply, and the requirements and restrictions of their respective medical schools (such as the number of clerkships students are allowed to schedule in one field or how many away rotations students are allowed). Moreover, students should assess whether or not they are the type of person who likes to be the first to do something (setting the standard to which others are compared) or the last (in an attempt to gain an advantage by being compared to preceding rotators while at the same time having gained skills in and familiarity with EM).
      Therefore, the optimal time to schedule an EM clerkship differs among students and is highly individualized. However, students should be aware that scheduling the rotation too early might affect their ability to impress faculty as much as they hope because they may lack pertinent clinical experiences from foundational clerkships (e.g., cardiology, radiology [including point-of-care ultrasound], intensive care medicine, trauma, or an internal medicine subinternship) (
      • Garmel G.M.
      Getting the most from your emergency medicine student clerkship.
      ). Conversely, the later students schedule their EM clerkship, the more clinical skills and acumen they possess, although evaluators may have higher expectations. Scheduling a key clerkship too late may result in delays in the receipt of evaluations and requested letters of recommendation, which are best when submitted well before the Electronic Residency Application Service (ERAS) deadlines and before residency programs review applications to determine which students to invite for an interview. A late clerkship might result in applicants not being offered an interview at a desired program. Despite the advantages and disadvantages to each strategy and each timeline, most things generally even out for EM-bound students in the long run (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ).
      If possible, students should identify the dates and locations of national and state chapter professional society activities, meetings, and conferences as they plan their clerkships in EM. Clerkship and program directors may attend these meetings and therefore not be at the hospital during a week or more of the rotation, potentially limiting exposure to these key faculty. On the other hand, students can strategize and schedule their clerkship geographically near or during these meetings using this information, and possibly attend some or all of the meeting. A number of these conferences include activities geared toward students, such as medical student forums introducing programs to potential applicants or education sessions with information focused at medical students provided by EM faculty from around the country.
      It is even more important to be cognizant of the timeline of the overall process. For example, ERAS for Accreditation Council for Graduate Medical Education–accredited residency programs for 2020 began when MyERAS registration opened June 6, 2019. The National Resident Matching Program (NRMP) registration for the 2020 main residency match opened September 15, 2019; the standard applicant registration deadline was November 30, 2019 (applicants incur a late fee after this date, although many programs will not accept applications beyond this date). The Medical Student Performance Evaluations (MSPEs, formerly known as Dean's letters) were released October 1, 2019. More information is available under the “Applying to Residency” tab on the Association of American Medical Colleges website (https://students-residents.aamc.org). Given these dates, interview season is typically open between October and February, with heavy focus between November and January at most programs. Some programs offer interviews during the major holidays, as this is convenient for students visiting family locally. Rank Order List (ROL) entry typically opens for students mid-January; the ROL Certification deadline is February 26, 2020. The main residency match results are available the third Friday of March, with the Supplemental Offer and Acceptance Program starting immediately prior to that (
      The National Resident Matching Program
      2019 Main Residency Match Calendar.
      ). These dates change slightly each year to avoid weekends and holidays. Letters of recommendation (LORs) from EM faculty (referred to as Standardized Letters of Evaluation [SLOEs]) are best submitted well before November 1, with the recommended “deadline” mid- to late-September, if possible (
      • Garmel G.M.
      Achieving success in medical school, the match, residency, and emergency medicine. AAEM 13th Annual Scientific Assembly, Medical Student Track.
      ,
      Boston University Medical Campus
      Timetable for Residency Application Class of 2019.
      ). Due to the increased number of applications at programs in EM, many programs have started evaluating candidates in early October; some even offer interviews before the MSPEs are released. Data from the 2018 NRMP demonstrate that 6% of program interview offers were extended, and 2% of program interviews were conducted, prior to October 1 (
      ). Therefore, the earlier months of the final academic year (between July and October) are generally preferred (and therefore most competitive) when scheduling EM clerkships (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ,
      • Garmel G.M.
      Getting the most from your emergency medicine student clerkship.
      ).

      How Many EM Clerkships Should Be Completed?

      The general consensus from most student advisors and clerkship and program directors is that 2 EM clerkships are sufficient for the majority of students. This provides students ample exposure to principles of EM, as well as insight into the inner workings of the specialty (such as shift work and circadian rhythm disruption, multi-tasking, pace and uncertainty of clinical practice, and the opportunity to interact with various support staff and consultants). Additionally, 2 EM clerkships should allow students to evaluate, manage, and propose dispositions for a reasonably large and diverse number of patients. Two EM clerkships provide students the opportunity to be exposed to different clinical environments, patient populations, and physical ED setups, all vital in helping students make decisions regarding how they want to train, as well as the setting and location where they might like to train. Furthermore, 2 well-timed EM clerkships should allow enough faculty contact to request and obtain SLOEs needed for the application process (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ,
      • Garmel G.M.
      Achieving success in medical school, the match, residency, and emergency medicine. AAEM 13th Annual Scientific Assembly, Medical Student Track.
      ).
      Some medical schools limit the number of EM clerkships a student is allowed, which may frustrate students. However, this is reasonable because scheduling more than 2 EM clerkships will likely limit the breadth of clinical education. Students must also factor in which clinical experiences they want “under their belt” before their first (or second) EM clerkship. If possible, it is important to have completed core clerkships in surgery, medicine, pediatrics, and obstetrics and gynecology before scheduling an elective clerkship in EM (
      • Garmel G.M.
      Achieving success in medical school, the match, residency, and emergency medicine. AAEM 13th Annual Scientific Assembly, Medical Student Track.
      ). Advanced clerkships in cardiology, radiology (including ultrasound), trauma, orthopedics, anesthesiology, or critical care medicine will almost certainly help students feel more comfortable in the ED, or at least enable them to bring more knowledge to the clerkship. This should help students perform better and provide better patient care during their subinternship in EM. It may even afford students the opportunity to teach other students who lack this experience, which is likely to be noticed (and appreciated) by EM faculty if done carefully with good intentions.
      There may be special circumstances in which scheduling 3 EM clerkships is warranted. These circumstances include students planning clerkships at more than 1 competitive EM residency program (“audition” rotations) where they are interested in training, or if they are having difficulty deciding on a best fit for their residency training and want to explore different types of residency cultures/hospitals/patient populations. If a student did not perform well in his or her core clerkships, or perhaps their initial EM clerkship, they might benefit from more opportunities to demonstrate their positive personality, their desire to learn, their commitment to EM, and, most importantly, their capacity for improvement and clinical excellence (
      • Garmel G.M.
      Achieving success in medical school, the match, residency, and emergency medicine. AAEM 13th Annual Scientific Assembly, Medical Student Track.
      ).
      For some medical students, it may be reasonable to schedule only 1 EM clerkship. This might be the case for an exceptionally strong applicant with a great deal of exposure to the specialty, or someone who has a unique relationship with key EM faculty at an institution, such as the program director, research director, or student clerkship director. The same also applies to students with successful research in EM or those who have important leadership positions in organized medicine, especially if they are familiar with the program where they desire to train (such as a residency program affiliated with their medical school). However, scheduling 1 rotation raises the concern of not having enough EM exposure to determine whether this specialty is right for them. Students who schedule only 1 EM clerkship should expect questions from residency program leadership during interviews about how and why they made the decision to schedule only 1 clerkship in EM and how they reached the decision to train in EM.

      Where Should Students Rotate for Their Emergency Medicine Clerkship?

      This is an extremely personal and subjective decision for students. Students should start considering where to do their EM clerkships as early as the beginning or middle of the core clerkship year (typically the third year for most medical students). Planning a rotation at a hospital affiliated with their medical school is recommended, especially if it has a strong EM residency program with a focus on medical student teaching and education. Skipping a rotation at your home institution might raise “red flags,” even if you are not interested in the program. On the other hand, if the student's medical school does not have an EM residency program, it is recommended to schedule an EM clerkship affiliated with an EM program that the student might consider for residency training, particularly one with a strong reputation for student education (
      • Garmel G.M.
      Achieving success in medical school, the match, residency, and emergency medicine. AAEM 13th Annual Scientific Assembly, Medical Student Track.
      ,
      • Jones K.
      Choosing an away rotation.
      ). Students must remember that not all EM programs have close ties with medical schools (although most do). More importantly, not all medical schools have EM residency programs, which makes clerkship spots even more challenging to secure if not researched and scheduled early. The Society for Academic Emergency Medicine (SAEM) offers a detailed clerkship directory at: https://www.saem.org/resources/directories/clerkship-directory.
      Scheduling at least 1 EM rotation at their home medical school provides medical students with the greatest (or certainly easiest) access to EM faculty, in a setting where they are familiar with the hospital “culture,” electronic medical record (EMR), a few of the consulting faculty and residents, and the educational climate. One additional advantage to this strategy is the opportunity to live at home during the rotation, which should reduce stress and allow more time for study (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ).
      In almost every situation, the second EM elective should be at a site different from that of the first rotation. This may grant the medical student exposure to a new hospital and educational environment, a new region or state, a different ED design and workflow, a different patient population, and a different style of EM practice. Arranging such an opportunity will also help solidify the student's career choice, improve the chance to obtain additional SLOEs, and provide an opportunity to impress faculty at a desired program (
      • Coates W.C.
      • Gill A.M.
      Emergency medicine sub-internship—a standard experience for medical students?.
      ). An EM rotation at a hospital not affiliated with a student's medical schools (an “away” rotation) provides an opportunity to “audition” at a residency program where they intend to apply in the future. It provides a tremendous opportunity to make contacts prior to, and necessary for, the residency application process. Furthermore, it gives students the chance to compare and contrast strengths and weaknesses between programs. It is important to note that programs are on display for students as much as students are on display for programs. Accordingly, students should use this opportunity to gather information about the intricacies of the program. This includes paying close attention to the interactions among residents, faculty, and support staff, which can provide a window to the culture of that program and the emergency department (ED). A successful rotation typically guarantees an interview, and definitely increases a student's odds for matching with that program (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ). Some programs offer “automatic” or abbreviated interviews for all rotating clerkship students; others do not offer interviews to rotating students because they consider the rotation to serve as the interview. This might frustrate students if they are not invited for a formal interview, although this approach allows programs to interview additional competitive students during interview season.
      Given the fact that spots for visiting students are often limited, students are expected to plan several months in advance, especially during competitive months at competitive programs. In fact, some programs require a letter of intent or short essay, application materials including a resume or curriculum vitae, medical school transcript, proof of citizenship, other documents, and a supporting letter from an EM faculty or dean that demonstrates serious interest in that clerkship, that program, and EM. A few programs require a small (but possibly significant) application fee or deposit for visiting clerkships. Although this may seem like an obstacle, these items are generally requested to make sure that applicants are serious about the clerkship experience being offered (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ). Remember to arrange for housing in advance. This may be difficult or take time to secure, depending on the location and popularity of the clerkship. Some medical schools or clerkships offer lists of available housing for visiting students.
      In summary, it is generally recommended to schedule the first clerkship at the student's home institution early, following it (if possible) with a second clerkship at the residency program or in the area where a student would like to match (
      • Garmel G.M.
      Getting the most from your emergency medicine student clerkship.
      ). If the home institution lacks an EM clerkship, the best strategy might be to schedule an early first clerkship at an institution known for student education, with a second clerkship at another site with a structured commitment to student education or residency training (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ). Generally speaking, if a residency program in EM is considered a good place to train, the student clerkships are quite competitive and educational. If your medical school has an EM residency program where you would like to train, scheduling a home EM clerkship after an earlier visiting clerkship might be a reasonable plan, if possible.

      LORs

      LORs from key faculty at established EM residency programs with whom applicants worked during their clerkship generally carry the most weight, all other things being equal. EM faculty involved in the residency selection process often know each other, are consistent in what they consider qualities of a strong applicant and signs of a potential “problem” resident, and they take seriously the responsibility of providing credible recommendations (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ,
      • Chiao A.
      • Garmel G.M.
      Letters of recommendation.
      ,
      • Garmel G.M.
      Letters of recommendation: what does good really mean?.
      ). This is especially true of more senior EM faculty. Applicants should take advantage of EM clerkships affiliated with an EM residency program offered at their medical school. Significant weight is given to letters from emergency physicians at EDs affiliated with an applicant's medical school because these physicians often have ongoing relationships with the institution. They often spend more time with students, may have more experience evaluating students, and may therefore provide a more objective evaluation. In addition, they can compare students with those who have trained in the same clinical environment (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ,
      • Rogers R.L.
      • Wald D.A.
      • Lin M.
      • Zun L.S.
      • Christopher T.
      • Manthey D.E.
      Expectations of an emergency medicine clerkship director.
      ).
      There are 2 types of LORs: traditional or narrative LORs (NLORs), which are subjective and written in prose (
      • Dirschl D.R.
      • Adams G.L.
      Reliability in evaluating letters of recommendation.
      ,
      • Morgenstern B.Z.
      • Zalneraitis E.
      • Slavin S.
      Improving the letter of recommendation for pediatric residency applicants: an idea whose time has come?.
      ), and SLOEs (formerly referred to as SLOR), which have a higher inter-rater reliability (
      • Girzadas Jr., D.V.
      • Harwood R.C.
      • Dearie J.
      • Garrett S.
      A comparison of standardized and narrative letters of recommendation.
      ,
      • DeZee K.J.
      • Thomas M.
      • Mintz M.
      • Durning S.
      Letters of recommendation: rating, writing, and reading by clerkship directors of internal medicine.
      ). SLOEs have been standardized to reflect a national curriculum using 6 core competencies; these include patient care, medical knowledge, problem-based learning, interpersonal and communication skills, professionalism, and systems-based practice (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ,
      • Swing S.R.
      The ACGME Outcome Project: retrospective and prospective.
      ,
      • Manthey D.E.
      • Ander D.S.
      • Gordon D.C.
      • et al.
      Emergency medicine clerkship curriculum: an update and revision.
      ). Students should expect comments and scoring of their performance on these core competencies in their evaluation (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ,
      Council of Emergency Medicine Residency Directors
      CORD Standardized Letter of Evaluation (SLOE).
      ). The SLOE is available at https://www.cordem.org/esloe. Students should be familiar with their content. There is currently no consensus on the exact number of LORs or SLOEs an applicant needs. At least 2 SLOEs from 2 different clerkships generally suffice. This tends to be preferred over 2 SLOEs from the same clerkship (because these are often identical) (
      • Garmel G.M.
      Mentoring medical students in academic emergency medicine.
      ). Additional SLOEs or NLORs can be obtained and submitted in a targeted manner to specific program(s) an applicant is considering, based on research, leadership, volunteer activities, or activities (including clinical) from non-EM experiences and non-EM faculty, on a case-by-case basis (
      • Boysen-Osborn M.
      • Andrusaitis J.
      • Clark C.
      • et al.
      Retrospective cohort study of the effect of home institution on emergency medicine standardized letters of evaluation.
      ,
      • Garmel G.M.
      • Grover C.A.
      • Quinn A.
      • et al.
      Letters of recommendation.
      ).

      How Do I Negotiate the Process of Selecting and Applying for an EM Clerkship? Logistics for an Away (“Audition”) Rotation

      Applicants should think and plan ahead. The best approach for medical students to make the most of their clinical years is to create an academic calendar which includes examination dates and required rotation dates. Students can then plan their most important electives during “open” time. They should confirm early on whether or not their medical school allows rotations at outside hospitals. In most cases, administrators will have a list of conditions (including mandatory paperwork) that must be met. This takes time and the process can be tedious, so students should be prepared and have a clear plan.
      Locating and securing an outside rotation in EM starts by gathering information about specific EDs and EM residency programs. The best resources are EM faculty (in particular, clerkship directors, program directors, and faculty leaders of EM interest group). EM interns and residents at the home medical school are also good (although often biased) resources. Graduates from the student's medical school who ended up in EM residencies across the country may be willing to provide help. The medical school should have a list of graduates and programs where they matched in the Dean's office or in the office of curricular (student) affairs. These individuals should be able to offer insight about the quality and character of residency programs and clerkships.
      Websites of societies and associations, such as SAEM (www.saem.org), the American Academy of Emergency Medicine/Resident Student Association (www.aaemrsa.org), and the Emergency Medicine Residents Association (EMRA) (www.emra.org) have sections dedicated to medical students. The SAEM website provides an EM Clerkship Primer (guide for a successful clerkship) in addition to an outstanding medical student rotation information guide arranged by state. The guide includes clerkship and program directories and considerable additional resources. Contact names, prerequisites, and information about the hospital and ED setting at each rotation are also available (
      Society of Academic Emergency Medicine
      Medical student resources.
      ). Students should be aware that some of the information on this and other sites may not be current. Websites from specific residency programs and clerkship opportunities generally provide current details, although these must be identified separately. Being resourceful and searching for key words such as student clerkship emergency medicine Florida comes up with a number of options and websites.
      Medical students should also consider attending a residency fair at a national or local meeting. This will help contact programs, meet key faculty (and residents), provide information, and might even assist in getting a coveted spot as a visiting student. Programs may be more likely to offer a visiting student clerkship spot to someone they have met or have developed a personal connection with rather than an applicant who has likely submitted interest to dozens of clerkships.
      EMRA's Student-Resident Mentorship Program is another method of learning about clerkships and their reputations. Blog sites or student forums that post information, experiences, or questions pertaining to clerkships and residencies may also be useful resources (
      The Student Doctor Network.
      ). One should be aware that these websites are full of opinions based on individual experiences, not necessarily facts, and may not reflect the experiences of others.
      AAEM's Medical Student Ambassador program provides an additional opportunity to meet clerkship and program directors, key academic faculty at many EM residency programs, and other students at a national meeting. Students who volunteer and serve as ambassadors are paired with faculty mentors at the AAEM Scientific Assembly, and benefit from the opportunity to ask questions about residency training in emergency medicine. More information about this program is available at https://www.aaemrsa.org/get-involved/students/medical-student-ambassadors.
      Once students determine where they would like to rotate, they should begin by contacting the EM residency program or the Graduate Medical Education (GME) office of the target medical school or hospital and inquire whether clerkships are offered in EM to visiting students. If so, they should ask to be directed to the appropriate contact person and the current application webpage. This information is often available on a webpage dedicated to EM clerkship electives (selectives). If students are unable to determine how to apply or are having difficulty getting a spot for an away rotation, they can contact the EM administrator or residency coordinator directly and verify the name, phone, and e-mail of the medical student coordinator or director. Contacting the coordinator electronically is the most appropriate initial approach. He or she will probably be difficult to contact by phone, although it is certainly worth the effort if a phone number is provided. In an e-mail, students should introduce themselves by stating their name, their medical school, and their expected date of graduation (i.e., stage of their clinical training). Students should include that they are in good standing, if this is the case. Additionally, students should indicate their interest in doing a residency in EM and explain that scheduling this EM clerkship is an opportunity to learn more about their ED and program. Students should also specify the specific dates during which they are available, while inquiring whether there are openings for visiting students during that time. Clerkships may not have flexible start dates (so that students all start together), but it is reasonable to ask about this. Clerkships may restrict the number of days students are allowed to be away (e.g., to interview), and may also have mandatory rotation requirements (such as a lecture or a standardized test during the clerkship). Students can conclude e-mails by providing their preferred contact information (e-mail, phone number, and mailing address). If students do not get a response within 1 or 2 weeks, a follow-up e-mail or a phone call is the next best step. If this proves unsuccessful, another option is to ask an EM faculty advisor to contact the clerkship or program director. This may result in the extra push needed to secure the elective clerkship. By engaging a faculty advisor as your advocate, this can capture the attention of clerkship faculty and staff and may help the student's “position” on a waiting list (
      • Darvish A.H.
      • Vallee P.A.
      The role of an emergency medicine clerkship: how many and where?.
      ).
      Once students receive approval to do a rotation in the ED, they should call the GME office immediately (as well as the appropriate office at their medical school) and complete all mandatory forms. It is possible that vaccination records or health care status may be required. The GME office or clerkship coordinator may be able to suggest housing, assist with parking (if available), and provide other rotation specifics (
      • Jones K.
      Housing for your away rotation. EMRA website.
      ). Students should also request and review “information packets” in advance, which are generally extremely helpful for visiting students, and are usually available from hospitals or clerkship directors with frequent medical student rotators. Students can ask which reading materials are preferred at that institution for the clerkship and get started reading. The application process for visiting EM clerkships is institution-dependent. Some institutions require that a completed application be submitted by the student before consideration for an EM clerkship. Other institutions may not offer flexible start and end dates. Most may not support your request for numerous days off to interview at other programs during the rotation; keep this in mind when you plan your “away” clerkship(s). A significant number of programs require transcripts, U.S. Medical Licensing Examination Part 1 scores (or verification of a passing score), and an LOR to be considered for an EM elective clerkship. These might take time to collect. Institutional requirements vary, and likely include strict enrollment periods, deadlines, firm medical and malpractice coverage requirements, proper affiliation agreements, or an application fee (
      • Darvish A.H.
      • Vallee P.A.
      The role of an emergency medicine clerkship: how many and where?.
      ).

      Tips on a Successful Rotation

      Students should keep in mind that “you never have a second chance to make a first impression.” The clerkship is considered a month-long job interview by most residency directors, therefore, students should do their best to behave like a model “resident” during their stay. They must recognize that although intelligence and clinical acumen are important, professionalism, character, humility, and commitment are crucial. Punctuality is extremely important in EM. If possible, students should arrive early for every shift and every residency activity that they attend. They should also be prepared, which includes reviewing course materials, instructions, and expectations before their rotation begins. Enthusiasm for their clerkship and residency program, being prepared and professional, getting along with others, and demonstrating an interest in EM and the program are essential components for a successful rotation. Clerkship and program directors look for a student's potential for success in EM; they do not expect students to know everything (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ,
      • Mahadevan S.V.
      • Garmel G.M.
      The outstanding medical student in emergency medicine.
      ).
      For any clinical rotation, the keys to success include (but are not limited to) enthusiasm, humility, productivity, professionalism, and integrity. For EM clerkships, there will be a variety of methods by which students are assigned shifts and patients. The attending physician or senior resident usually assigns a patient with educational value to a student, when he or she is or should be ready for another patient. Some students are expected to “sign up” for patients, but this can be tricky, as students must make sure not to overextend themselves. Alternatively, some departments may pair a student directly with an attending physician, either for the entire month or for each shift. Whatever the case, students should learn the system, introduce themselves to these individuals before the start of each shift, and demonstrate enthusiasm for the opportunity to learn from every patient. As much as possible, students should strive to be on top of their patients' test results, be kind to every patient, gather relevant and important data on every patient, and be instrumental to their patients’ care.
      It is important for students to establish themselves as intelligent, efficient, qualified, and courteous professionals. This can be achieved through thorough history-taking, meticulous physical examinations, broad yet focused differential diagnoses, and comprehensive medical decision-making. Taking a few moments to organize one's thoughts before launching into the case presentation or seeing the next patient is a good idea. There are several excellent articles and videos about how to present a case (
      • Davenport C.
      • Honigman B.
      • Druck J.
      The 3-minute emergency medical student presentation: a variation on a theme.
      ,
      Patient presentations in emergency medicine.
      ). Additionally, confidence and precision are necessary to make important decisions pertinent to patient care, including diagnostics, therapeutics (not necessarily in that order), consultation if appropriate, and disposition. Continuous follow-up on laboratory and radiology studies, careful attention to detail, and updates regarding responses to therapies helps students impress residents, faculty, and nurses. Many students feel that seeing a lot of patients will impress the residents and faculty. However, not following patients closely not only jeopardizes patient care, but is typically interpreted as a negative. Nothing is more impressive than a student who follows his or her patients closely, is able to provide accurate clinical updates, is aware of laboratory and radiology results, and has a reasonable plan of action based on these findings.
      Patient safety is another key component of a successful rotation. One of the hardest things to remember as a medical student is to identify potential life-threatening causes of pathology (
      • Garmel G.M.
      How to shine and get the most from your EM clerkship.
      ). Students should ask for help immediately if they need it, or if a patient “looks sick.” Nothing can ruin a clerkship experience or put patients at risk faster than doing something inappropriate because the student was overconfident or afraid to ask for help. A balance between an exhaustive history and extensive physical examination and performing a focused assessment in a potentially ill patient must exist. This also extends to refraining from performing procedures or ordering laboratory tests without first discussing with the resident or attending. At the end (or even during) a shift, it is essential to ensure the adequate transfer of all patients. Transferring the responsibility of a patient's care and the details of his or her presentation, management, what was done, and what is pending to another team member as detailed by the clerkship workflow is the extremely important process known as “sign out” or “handoff” (transitions of care). Important in all of medicine, this process is especially significant in EM. Given all of this, students must remember that they are not expected to do the work of a resident. However, they should do their best with every patient they manage and follow them closely (
      • Hayward A.
      Clinical clerkship clues: emergency medicine. The Student Doctor Network.
      ).
      Students are expected to be receptive to both criticism and praise. They are also expected to solicit feedback and teaching if neither is offered (assuming appropriate timing and conditions exist). Another way students can impress others while increasing their learning is by following up on interesting patients who were admitted to the hospital, taken to the operating room, or even discharged from the ED (patients generally appreciate a phone call the following day, although it is best to discuss this in advance with an EM faculty because it may require documentation in the EMR). Students can then share this information at an appropriate time with the resident, faculty, and staff involved in that patient's care. Students must always respect patients' privacy when discussing cases and should never post about patients on social media. Students should also prepare in advance for conferences by reading about the topics for that week, as this will get noticed and also allow for better comprehension and retention. This also applies to preparing and rehearsing a presentation on a topic or interesting patient (which might be required) and teaching student colleagues. Students are advised to read about every patient every day. This effort should improve the learning experience from the clerkship; it may also leave a positive impression on evaluators and potential future colleagues.
      Novel ways to increase student learning from EM clerkships have been introduced. An “Interesting Case” discussion board for the clerkship provides students working at different times and different sites the opportunity to post cases they encounter during their rotation and share them with colleagues (
      • Wald D.
      • Fane K.
      • Barrett J.
      Incorporating an interesting case discussion board into an emergency medicine clerkship.
      ). It is imperative that patient privacy is protected and maintained in these posts. Additionally, a “flipped classroom” exists at some EM clerkships, where medical students are provided online modules that focus on a chief complaint prior to their shift, followed by chief-complaint–focused learning during their shift (
      • Heitz C.
      • Prusakowski M.
      • Willis G.
      • Franck C.
      Does the concept of the “flipped classroom” extend to the emergency medicine clinical clerkship?.
      ,
      • Lew E.K.
      Creating a contemporary clerkship curriculum: the flipped classroom model in emergency medicine.
      ). Some institutions encourage the use of Free Open Access Medical Education, valuable interactive resources available on the internet (
      • Welsh L.
      • Parekh K.
      • Brumfield E.
      FOAM in the EM clerkship: clerkship director attitudes and practices using FOAM in emergency medicine clerkships.
      ,
      • Burkholder T.W.
      • Bellows J.W.
      • King R.A.
      Free open access medical education (FOAM) in emergency medicine: the global distribution of users in 2016.
      ).
      At the end of their clerkship, students will be formally evaluated. Most clerkship directors will offer formative and summative feedback. Students are still advised to seek feedback after every patient or at the end of every shift. Evaluations are typically done with input from residents, faculty, nurses, and staff who are comfortable sharing their impression of a student's performances. Students should therefore keep in mind that anyone can contribute to a composite evaluation during their clerkship (including patients and patient family members).

      Conclusions

      Planning for EM clerkships should start early. For numerous reasons, an EM clerkship scheduled between July and October is most advantageous. Two EM clerkships at different sites with a focus on teaching and patient care should be sufficient for the majority of students. EM clerkships associated with residency programs or with reputations for outstanding student teaching are often most beneficial. Above all, students interested in EM should remember to “put their best foot forward” and make a great impression during their clerkships by providing stellar patient care, demonstrating enthusiasm at all times, and being professional. In turn, students will gain knowledge from clinical experiences that should prove valuable for future success.

      Acknowledgments

      This work was supported by the Department of Emergency Medicine at the American University of Beirut Medical Center, Lebanon. The funding source was not involved in the preparation of the article, writing of the report, or decision to submit the article for publication. This research received a nonrestricted educational grant from the not-for-profit Resident Student Association (American Academy of Emergency Medicine) and the Department of Emergency Medicine at the American University of Beirut.

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