| Required Rotations
Nuts and Bolts (for any sub-internship) Dan Oates ’00 Once you find out what block you are assigned, you can choose what side to do it on (as you will not yet be assigned to a campus, just BMC.) I suggest you call (8-6500) or visit (Evans 124 – go down the hall past the Dean’s Office, through the gray doors and it is the first office on the right) the Medicine Residency Office and find out who the residents will be for each side (super sub- I teams are A1 at HAC and E2 at ENC). Pick which side you want to work on based upon the residents – as they make or break this rotation. You will be paging your residents ALL DAY – sometime more than 30 times a day – and you need to have someone you feel comfortable working with and asking stupid questions. If you’ve never heard of the residents- ask your classmates about them. After you decide which side you’d rather have, call Deborah Jones (8-8030) and put in your request. She’s generally able to accommodate your request. Regular sub-Is may request a certain team. Learn how to use your pager. If you’re on the BMC system – change your status to "Out of hospital" when you leave – or nurses WILL page you at 11:30 at night. To change your status, dial into the paging system and push the star key after you enter your pager number. There will be a few seconds of silence, but then follow the instructions. Remember to change it back in the AM. Whom should you sign out to? Sign out to the sub-I on the long call team. However, that person should give all of the sign-outs to the night float intern when he gets in at 7 PM. Learn how to be aggressive!!! The people who work in admitting and in the lab are TOTALLY INCOMPETENT!!! Do not be shy when the lab loses your specimen or when admitting calls you again when it’s not your turn in the rotation. Speak up…but try to be a bit nice if you can, as the power these people can have over the length of your day is truly disgusting. You may not have much time to attend conferences, but don’t feel bad. Sometimes it is more important to get home an hour early and just veg out with a movie than to go to noon conference. Don’t feel bad about not reading at night… we are only human and need to sleep sometime. If you feel overwhelmed LET YOUR RESIDENT KNOW!! Interns will try to take advantage of the fact that you are a student trying to honor your rotation and therefore that you won’t speak up if you get too much work. On the super sub-I teams, the two sub-Is are supposed to be one intern, so together then two students should take ½ of the admissions. Often times that is too complicated for admitting to handle (remember they are incompetent!!) so you will get 1/3 of the admissions. If you feel overwhelmed, let your residents know (if you have a very good resident they should recognize you’re overwhelmed and intervene before you have to tell them). Getting sign out from the ER is a real art. The first few times you get sign out from the ER, try to do it with your resident sitting next to you, as they will help you figure out the pertinent facts you should find out on sign out, as you will be amazed how little info the ER will give you on sign out. BEFRIEND THE NURSES!!! Treat them well (don’t argue with them… leave that to your resident who probably knows them better) and they will help make your life much more bearable. Medicine It is important to keep in mind that your sub-internship experience is not only resident dependent but also attending dependent. Much of your rotation is what you make of it. The design of this clerkship resembles the 3rd year medicine in that you are not assigned to cross-cover or to get direct calls from admitting; however, the expectation is generally the same for both the sub-I and the super sub-I – to be the sole provider for the patients. You are expected to carry between 4 to 6 patients.
JP VAMC Liz Y. Han ’00 I truly believe that that the VA is a treasure for medical students, especially when it comes to the medicine sub-internships. Among the five medicine teams at the VA, one regular sub-I is assigned to one team, and another team receives 2 super subs such that no more than three 4th year students are working there at any given time. The VA patients, as noncompliant as they may be, are a patient and fun lot. They thoroughly enjoy the medical students. Furthermore, Dr. Caslowitz, who is very fair and knowledgeable, attempts to ensure that learning is constant and that you are not just being scutted out. Your day starts around 6:30 AM for pre-rounding. 7:00 AM marks intern conference which the 4th years are welcomed to attend; this conference is taught by the chief residents. Your team starts to swing into gear between 7:30 and 7:45 with official rounds. There is noon conference (but not always accompanied by lunch). Attending teaching rounds with the team are similar to that at BMC, that is every MWF at 10:30 AM to 12:00 AM. Attending quality is widely varied at the VA. My own experience with my attending was less than ideal since he "taught" by demoralizing me with pimpings. It is important for you to voice your concerns early on to Dr. Caslowitz, the chief residents and your own resident if you feel that you are not being treated fairly. In between all of this conference, you are to complete orders and consults. Because everything is computerized at the VA yet your orders will sit in the system unless your residents get around to co-sign them, expect longer time span for orders and consults. By the way, there is no A/C at the VA…prepare to cook if you are there during the summer months.
Advanced Acting Internship in Medicine at BMC Dan Oates ’00 Four students per block are chosen to be super sub-I’s at BMC. Students will work on Firm A at HAC and on Firm E at ENC. On the super sub-I teams, two sub-I’s work to replace one intern – so the ward team has one junior or senior resident, one intern, two fourth year students and a third year student. In order to apply for this, one must sign an application/contract – which needs to be signed before you even know in which block you will have your sub-I–and if you are chosen you MUST complete the sub-I in the assigned block. It is almost impossible to switch out of this if you suddenly decide you don’t want to do it. The quality of this rotation is entirely dependent upon who your resident is (since you will be working more closely with him than you have worked or will work with any resident or intern at any other time during your third or fourth year). I felt this was even more important than who your attending is. How much work it is depends upon when you get assigned (as the super sub-I is offered June through mid-December). BMC is generally much less busy during the summer and gets progressively busier during the fall heading into the winter. It has the potential to get rather busy – as you will be responsible for 1/4 of the patients on your team and some students have had up to 10 patients (mostly those who did it in Oct-Dec.). Generally this rotation can really be a rather extraordinary experience – as you really feel like a resident (and generally the nurses treat you with much more respect than they did when you were a third year student) and you find out what it is like to be the one primarily responsible for a patient and get all of the first calls when something is wrong (i.e. your patient is having chest pain or is desatting.) The issue many students grapple with is if having this on your transcript (as opposed to a regular sub-I) is worth the extra work. When you interview for residency, most places will not know that BU offers this "selective sub-I", so no one will ask you, "How come you only did a regular sub-I?" Many people feel a "new confidence" after doing this rotation, because if you can do this you really CAN HANDLE ANYTHING!!!! Surgery Ron G. Landmann, ‘00 The surgery Sub-I is a requirement if you are planning on a career in surgery. The biggest issues surrounding this rotation are when and where to do it. You should be strategic when planning this. If you can manage it, the Surgery Sub-I should be done within the first four or five blocks, so that the grade will get on your transcript. More importantly, you will need a letter from your preceptor, and it is important to be able to ask for one in a timely fashion. Blocks six, seven, and eight might be used for a Sub-I at an away site -- particularly one you are interested in for a residency. Deciding where you should do the Sub-I is up to you. The majority of students schedule it at ENC because they feel it is the best place politically speaking to get a letter of reference. However, the other sites of HAC and the VA are also advocated by some because they each have their unique characteristics and good teachers that will prepare and advise you well. (Dr. Hirsch is especially popular for those students going into the military.) For all of the Sub-I’s, take every chance you have to present cases at different rounds and conferences. Dr. Menzoian is a particular supporter of this in his Vascular rounds. In the past Dr. Babineau has not been very keen on having students present at GI Surgery conference, but Dr. Becker has been known to "stand up" for his sub-I’s and have them present… J Even if you are not on the Mozden service, you should take the time (it really is only one hour a week) to go to Dr. Beazley’s rounds. These are informal rounds with residents and students where you will gain a better appreciation of different surgical endocrine oncologic disease manifestations and treatment. No matter where or when you do this rotation, working hard and reading are the best ways to make a good impression. One other bit of advice, if you have third year students below you, take the time to help them out and teach them, too – remember, as a sub-INTERN, you will learn the most by being able to teach… Ron G. Landmann, ‘00 This is probably one of the "most-desired" sub-I’s for the wrong reasons. Granted, you will be working with the chairman of the department. However, even if you do not get the Chief’s Service, you can still get a letter from Dr. Becker – he will base it on third year evaluations and by talking to your Sub-I residents and preceptor. So, this leads us to what you will be doing on the Chief’s Service. It should actually be called the GI service. You will do an amazing variety of gastrointestinal cases. You will likely participate in at least two of Dr. Becker’s ilio-anal pull-through procedures (for UC or FPC). You will see many endoscopies with the chief as well. Also, there are clinic responsibilities two days per week (only fourth year students and residents go) with Dr. Becker. In addition, you will be working with Drs. Millham, Babineau, Forse, Sentovich, and occasionally Burke – each performing a wide variety of cases within their expertise… (laparoscopy, hepatobiliary, colorectal, etc.) You will get an occasional hernia or appy, too. These patients are usually more complex than traditional surgical patients and therefore are more interesting and challenging. Overall, this rotation is a great one to develop expertise in general (specifically GI) surgery – both operative and peri-operative care.
Smithwick Service Sub-I Ron G. Landmann, ‘00 This service is traditionally the vascular service BMC. This would be an exceptional service to work on if you are interested in general or vascular (of course) surgery, and orthopedics and urology. You will have the occasion to work with Dr. Menzoian who is an ardent proponent of students – and patients. Dr. Menzoian is well known throughout the country and many interviewers will ask about him. It is a true learning experience. Vascular patients are undoubtedly the sickest patients (second only to SICU patients) in the hospital due to their many underlying disease states and risk factors (DM, smoking, CAD, PVD, dialysis, etc.) – giving them the unfortunate label of "vasculopaths." However, after completion of this rotation, you will see an overwhelming type and number of vascular cases (from CEAs to AAAs, from aorto-bifems to fem-distals) and all their complications and difficult management involved. Truly, you will gain an increasing mastery of medicine and difficult surgical problems. While on the service, you will also work in Dr. Menzoian and Woodson’s clinic at DOB and occasionally go over to "the municipal" (a.k.a. BCH or BMC/HP) for interesting cases – there is a lot of vascular trauma. New vascular faculty has joined the department lately (Gibbons, et. al.) from the BI; however, it is not known how much interaction you will have with them. This was a great month and one that I most highly recommend.
Surgical Intensive Care Unit (SICU)This rotation is a popular one for those interested in surgery, anesthesia, or emergency medicine. Why? Well, because it is a month of treating very sick or injured people, and as such one can learn a great deal about the acute phase of illness and injury. Call is rigorous, being every other day. That is the worst part of this experience though, and for one month, it is well worth the time. Regardless of which hospital you are assigned to, you will be busy. Granted, there is more trauma at HAC, but there is a greater diversity of surgical patients in the ENC SICU. During this time, you will serve as an integral member of the Critical Care Medicine team, a service that is consulted regarding the peri-operative management of surgical patients. You will learn much about the pathophysiology of surgical disease, and the risk factors associated with operative care. Additionally, you will be well trained in the monitoring and treatment of critically ill patients. One of the most attractive parts of this rotation is the chance to learn and perform various procedures such as arterial and central line placements. The majority of the learning is achieved at the bedside, and the attendings and fellows are excellent. There is a weekly conference on topics or cases of interest in critical care. This is a fantastic rotation for anyone interested in a surgical or emergency medicine career. This was one of the best rotations I had in my time at BUSM, and I hope that you find it rewarding too.
During this rotation, students had total responsibility for their patients. Students admit their own patients and are responsible for all aspects of patient care. Morning rounds are from 8:00-9:30 AM. During morning rounds, students present any patients that were admitted the day before and are responsible for discussing with the team the plans for their patients. At 10:30 AM every day, the entire team attends X-ray rounds that provide a daily opportunity to correlate physical diagnosis and disease patterns with radiological findings. Attending rounds are scheduled three times each week at 11:15 AM. There is often an hour-long lunchtime conference at noon. The afternoon is spent completing the work for the day and admitting patients. Students are on call q4 (students are paired with a 2nd year resident) and call lasts until 10:00 PM. Students are guaranteed at least one day off each weekend. The rotation lasts a total of four weeks. This was an excellent opportunity to learn about the care of the pediatric patient. Students were involved in all planning regarding their patients and, in contrast to the third year rotation, were usually expected to devise their own plans. Sub-I’s usually carry three or four patients. The conference schedule is much less time consuming than that of the 3rd year pediatrics rotation at HAC, so students that were frustrated by the seemingly endless amount of conferences need not worry as much about this problem. In general, this Sub-I provides students the ability to have more responsibility for their patients and to learn a great deal about the care of inpatient pediatric patients.
Pediatric Emergency Medicine, BMC-HAC Bob Kiley ’00 The Pedi ER, even if you don’t do it as a sub-I, is a great experience, offering much more individual attention and hands on procedural experience than the Adult ER rotation. For all the ER yahoos out there, they are more likely to get their hands dirty in the pedi trauma room than in the adult ones.
The NICU is a great rotation if you are interested in pediatrics, emergency medicine, or intensive care training. The average daily census is 12 infants with a gestational age ranging from 28-36+ weeks. The neonates are in the NICU for a variety of reasons such as prematurity, hyaline membrane disease, etc. As a Sub-I, you will be responsible for 2-4 patients depending on your comfort level and the census. You will be working with a neonatology fellow from NEMC, two pediatric residents, two pediatric interns, and one emergency medicine resident. The call schedule is every 4th night, overnight. You should not expect to sleep. Attending rounds and radiology rounds take place every morning. The attending rounds usually focus on core topics or relevant topics in neonatology. Both of these are excellent educational opportunities. Morning rounds begin at 8:00 AM and you will be expected to pre-round on your patients. The day usually ends at 5:00 PM unless you are on call. You are allowed and encouraged to wear scrubs during the rotation; things can get messy at deliveries. The neonatologists, Dr. Alan Fuji and Dr. Elizabeth Brown, are excellent. I cannot comment on Drs. Mirochnick or Corwin since I did not work with either of them. While in the NICU, you will attend all of the high-risk deliveries and be allowed to take an active role in the resuscitation, with the exception of intubating the infants. You will be encouraged if not expected to take part in the Neonatal Resuscitation Program that is the equivalent of ACLS, but for neonates. Mock codes are also a part of the weekly teaching. The rotation overall is a great experience. The resilience of the neonates is truly amazing. Enjoy!
Although this is a required rotation you have a lot of flexibility in how and where you like to spend your time. This is a nice, relaxing, 9-5 rotation where you really learn a lot about how other factors (social, economic) play roles in a patients’ health care. There are several sites at Boston Medical Center as well as sites in the Greater Boston Area and Cape Cod. A rotation with the Indian Health Service (IHS) is a fantastic experience that will also fulfill the primary care requirement. The rotation may be done at any of the hospitals or clinics within our system. Each case must be presented to an attending, and all notes and orders must be counter-signed. All of the sites provide a excellent experience in general medicine, and more importantly, the opportunity to learn more about a different culture. The physicians at these sites tend to be younger, and very dedicated to the work they do. Additionally, they are excited to share their enthusiasm with students. While there, take some time to learn about the people living around you, and to explore the region! Rotations within the IHS system are very popular, and thus must be sought early. It is recommended that an interested student start researching the opportunities early in the third year, so that you may be assured of a spot in your fourth year. Call the Indian Health Service Office in Washington, DC, and request a listing of sites. Maine Ambulatory Care Coalition This can be a great experience, especially depending on what you make of it. Talk to Dr. Shaw early about doing a rotation in rural Maine, because these are very popular and there are not too many spots available. The Maine ACC periodically publishes a newsletter entitled "Bruit Rurale" which gives information about the electives that are available in family practice through their program. You should have received this publication in your mailbox. Even if you are not interested in family practice, this is a great rotation to do. Much of the diseases you see are similar to what you would see in Boston, however, it is quite a different experience to not be able to order bloods or an MRI emergently like you can in most other hospitals. The patients are all very nice and welcoming. You will occasionally do house calls. The experience is very different depending on what site you do it at, as there are many. There is so much to do in Maine, no matter what time of year it is, so be sure to explore as much as you can!! Home Medical Service/BU Geriatrics Service Geriatrics is a required rotation for all fourth year students. The student body is divided into teams and function mainly with the attendings working within these teams. The day generally starts between 8:30 to 9:00 AM, depending on where you are assigned, the location of which is divulged to you the previous afternoon. You will be paged by either Susan Cleaver or Jenny Hyun if you are late! Morning activities revolve around making up to six to seven house calls. Upon returning to campus, there is a lull until the required afternoon lecture that usually starts between 3:00 and 4:00. House calls generally involve a short history of present complaint, follow by a focused physical exam. Blood draws are sometimes done in the homes and dropped off at lab later on. House calls afford a wonderful opportunity for teaching that some attendings from the department do better than others. John Pak ’00 This requirement offers a glimpse of outpatient medicine that ostensibly serves to introduce 4th year medical students to management of the elderly. This regimented elective does not offer much flexibility in scheduling and, therefore, may not be ideal during interview season. However, it is the exceptional case when one is not home by 5:00 PM. As most students would agree, the experience is highly dependent on the clinical preceptor; some are fair and empathic, while others are simply difficult. Drs. Rosenthal and Barry appreciate 4th year medical students, deftly encourage participation in patient management as they see fit and reasonable, and constructively teach practical management issues in geriatrics. Therefore, attempt to pre-arrange a preceptor well before the elective. Much has been said about the secretarial staff. It is true, they know your every move. Dan Oates ’00 HAC is THE place you want to do neuro!! It is sooooo much better than any of the other sites. When you work at HAC, you will spend two weeks on the consult service and two weeks in clinic. The two weeks you spend in clinic will definitely be the best two weeks of the rotation. Clinic is held on ACC 4 and here you will see patients with a variety of neurological diseases – but the majority will have headaches, neuropathy, low back pain or seizures. Most of the time you will be asked to see the new patients – whom you will interview and do a complete neuro exam on and then present to the attending along with your recommendations for treatment. Generally, the attendings are very friendly in clinic and will teach you. Usually it is one attending and two or three students. The exception is Thursdays, which are very crazy, as three attendings all have clinic at the same time and it can get very backed up. The clinic nurse, Peggy, is VERY nice and will help you figure out the paperwork. Dr. Wiesman has clinic here Wed/Fri and does a very good job of teaching during her clinics. As with all HAC clinics the no-show rate is from 20% to 100%. This is probably the place that has the most teaching of any site in the entire neuro rotation. Here’s the best part…. clinic is only in the AM – so you may leave at noon!! If they try to make you do consult in the afternoon, ignore them – as there are too many students on consult already and adding two more makes it even more of a waste of time. The other two weeks are spent on consult – which is pretty much a waste of time. Here you will see mainly consults from the medicine service and the MICU. Most of the residents don’t ask you to see patients in the ER, although you may if you are very interested or motivated. The residents are called by the various services and may or may not let you know that they have a new consult. Most of the students hang around with their resident during the day and find out about consults because they happen to be standing next to the resident when they get paged. Generally the student conferences on Tuesday mornings were pretty good as were grand rounds. The other conferences are really hit or miss. Dr. Wiesman began "requiring" students to attend the morning report that happens weekdays at 7:30 at ENC. This is really not geared towards students at all and is a huge waste of time. Basically, the residents present new patients to the attending –but the discussion is more administrative, rather than focused on teaching. Your time is better spent sleeping, so you should not waste your time attending.
Primary care is a required 4 week elective that can be set up either by Dr. Shaw’s office or your own. Your schedule is highly dependent on that of your attendings, most of whom work a fairly heavy load as dictated by the HMOs. John Pak ’00 At Caritas Medical Group with Dr. Kim J. Scola: Belmont, MA 617.497.0972 This internal medical group offers much flexibility for 4th year medical students. It is a low stress environment well suited for anyone. Dr. Scola is a BUSM ’96 alumnus who understands the learning curve of the 4th year medical students. He does not pimp students, but does appreciate the need to teach the practical management issues in general internal medicine, pediatrics, and geriatrics. All around, this is an excellent clinic with ample opportunity for hands-on practical medicine. There are optional grand rounds at local hospitals for the eager beaver and at least two drug luncheons per week. Two students participated during the spring of 2000 and both were extremely satisfied with their experiences. The staff is exceptionally helpful.
Attendance plays an important part in grading; however, it is recommended but not so enforced. Cynthia Mierzejewski ’00 This is a low stress, low key rotation. Morning talks with residents in which cases are reviewed with x-rays are excellent. The rest of the day is hit or miss depending on the lecture and the resident. The noon time lectures are usually too advanced since they are geared toward the residents. As course director says, "It’s what you put into it." He also likes to honor only those students pursuing radiology. [Dr. Blickman has attempted to dispel this rumor about grading through a class wide email this past year where he adamantly denies that this is the case. -Eds]
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