The Intensive Care Unit (ICU) is quite a unique environment in the hospital, one where seconds and minutes can mean the difference between life and death.

If you’re on an ICU rotation, it may feel overwhelming. While you can typically help in some bedside procedures like placing an arterial line, one way to really shine during this rotation is to give a great patient presentation! By being comprehensive and thoughtful, you can demonstrate your critical thinking skills and ultimately give your patient the best care possible.

This blog is tailored to the ICU presentation and the associated systems-based plan. Check out this general patient presentation template for a problems-based assessment and plan!

Here’s what you need to know when it comes to giving an ICU presentation.

📘 FREE Download: ICU Patient Presentation Template

Want a customizable PDF to fill out during rotations? Submit the form and get our ICU Patient Presentation Template download sent right to your inbox…for FREE! 🤩

What to Include in Your ICU Patient Presentation Template: A Systems-Based Approach

To give you some background, ICU rounds are a lot different than other rounds you may be a part of. They tend to run longer as patients are critically ill, and there may be several aspects of their care that are coordinated during rounds.

The following list of what to include in an ICU patient presentation isn’t intended to be comprehensive, as that would require a whole textbook! And it may vary a bit if you’re in the medical versus surgical ICU. But it should give you a good starting point.In your ICU patient presentation template, be sure to include:

The One-Liner

This is a succinct piece of information to orient the team to the patient.

Include the patient’s name, age, post-op day number if they had a recent surgery, and why they are in the ICU/diagnosis. 

Overnight Events

Include any notable events such as if intervention was required by a physician. For example, if a patient became hypotensive and required an additional vasopressor drip, or even a blood transfusion. Another example is the patient’s O2 sat becoming unstable and necessitating intubation.

Assessment/Plan

From here on out, you can jump into your systems-based assessment and plan (A/P). Some attendings may prefer for you to separately state the vitals, relevant labs, physical exam, and ins/outs before, but many will prefer for it to be embedded in the A/P.

Using a “head-to-toes” approach, we’ll proceed through each organ system in an organized fashion to make sure nothing is missed!

Taking it from the top, be sure to include: 

Neurological 

It can help to start with the Glasgow Coma Scale (GCS) of the patient. Be sure to add a “T” if the patient is intubated and remember the GCS can never be below 3!

Note any changes in a mental status and neurological physical exam. Also state if the patient is receiving any sedation like dexmedetomidine and the rate.

Then include an assessment of the patient’s pain level (if applicable) followed by what pain medications they’re on. Add if they received any PRN medication pushes. If they’re on a patient-controlled analgesic, mention how many times they’ve pushed the button. Suggest necessary next steps like changes in medications/drips, imaging, or a consult if needed. 

Cardiovascular

Discuss the patient’s heart rate along with the blood pressures/mean arterial pressures (MAP). (The MAPs are applicable when the patient has, for example, an arterial line.) Include the current rates of any vasopressor, vasodilator, and inotrope drips.

Based on the information you have, determine if the patient is in shock and if so, what type. Report on any diagnostic findings like EKG/echocardiography and cardiac labs like troponin and BNP if relevant. Similar to the neurological plan, suggest (for example) if the drips can be weaned and if any further workup is required. 

Pulmonary

Ventilators tend to be a big part of ICU management. Begin with a summary of how the patient reports their breathing (if they’re verbal). Any shortness of breath or heavy secretions?

If the patient is on a ventilator, review the current settings: ventilation mode, respiratory rate, tidal volume, PEEP, and FIO2. Include a recent arterial blood gas if available and how the patient’s oxygen saturation is. Report how the patient’s latest chest X-ray looks and if there are any chest tubes present, their outputs.

Plans for the pulmonary system include possible extubation, oxygen support adjustments, respiratory therapy, medication changes, and diagnostic testing like bronchoscopy or imaging.

Gastrointestinal

In this section, discuss any abdominal related diagnoses or surgeries. Update the patient’s current nutrition status: per os (oral) intake, total parenteral nutrition, or nil per os (NPO). State if the patient has any abdominal pain and if they’re having bowel movements.

Go over pertinent positive or negative lab values like liver function tests. Report the outputs and color if there are any abdominal drains. For a plan, you may suggest an abdominal X-ray if the patient is not passing gas, medications to treat diarrhea versus constipation, or management of a nasogastric tube. 

Genitourinary 

Discuss if the patient is having any pain or difficulty urinating. Be sure to check if the patient has any swelling in their legs to assess volume status. A measure of the jugular venous distension can also aid with this. 

This is a good place to report the ins/outs for the past 24 hours. Also report the urine output, often stated as milliliters/kilogram/hour. Include relevant labs like electrolyte abnormalities or creatinine as a measure of kidney function.

If the patient is on continuous renal replacement therapy (CRRT), check the settings and suggest if any modifications are required based on volume status. For example, if the patient is volume overloaded, the CRRT machine can pull more volume off.

Possible plans include removing the Foley catheter, suggesting dialysis changes, changing fluid rates, obtaining imaging or urine cultures, and consulting the nephrology service. 

Hematology

As before, begin with a subjective report. Does the patient notice any bleeding or fatigue?

Important objective information to report includes the trends in the hemoglobin/platelets/INR/PTT/PT and if there have been any blood transfusions.

Suggest if the patient requires a change in anticoagulation regimen, diagnostic testing, or a transfusion. 

Infectious Disease

This is a good time to discuss if your patient has a fever and if so, its trend. Also, be sure to go over white blood cell labs along with possible antibiotics, infectious disease recommendations, and blood/urine/wound cultures.

To shine in this section, suggest if you have a source for any infections of unknown origin. Does the patient need a line holiday?

Endocrine

Report if the patient has any overall fatigue and sensations of heat or coolness. Comment on blood glucose levels and TSH if applicable. Be sure to correlate glucose with the patient’s diet status.

As part of your plan, state if the patient needs insulin or any diagnostic workup for endocrine abnormalities.

Musculoskeletal 

Note if the patient has any joint or muscular pain. Any imaging results or orthopedic surgery recommendations are helpful to add. In your plan, add if physical or occupational therapy needs to be onboard for rehabilitation. 

Prophylaxis

 Towards the end, summarize the different prophylaxes the patient is on. For example, to prevent deep venous thrombosis, state if the patient is on anticoagulation and/or has sequential compression devices in place. If the patient is about to undergo surgery, it can help to say that anticoagulation was held. Also mention if the patient requires gastrointestinal prophylaxis like with a proton pump inhibitor. 

Disposition 

Conclude your presentation by stating what requirements the patient still has for ICU level care. For example, state if they’re in shock with pressor requirements, or have continued ventilator needs. If stable, perhaps they can be transferred to the floor.

Looking for some help studying your shelf/Step 2 studying with clinical rotations? Try our combined Step 2 & Shelf Exams Qbank with 5,500+ practice questions—free for 7 days!

4 Tips for Your ICU Patient Presentation

1. There’s no need to rush.

The purpose of the ICU presentation is to convey critical information in an organized fashion so it can be understood by the whole medical team. When you’re starting out, it may feel quite long.

Don’t worry—ICU rounds tend to run longer because the patients require such high-level care and it’s better to be comprehensive and efficient than to rush through rounds and miss something.

Once you get the hang of the format, you’ll notice the speed starts to pick up.

2. Focus on the most critical information.

Given the length of the ICU presentation, it’s best to focus on pertinent positives and negatives. For example, subjective responses are not always needed if they don’t add any valuable information. Listen to the presentations of others on rounds to determine what information is critical and what can be left out.

3. Organize information by system. 

Focus on organizing information by system. For example, spinal and biliary drain outputs should be reported in the appropriate section: neuro and gastrointestinal, respectively. Do the same with lab values.

4. Take all systems into consideration.

One key recommendation is to critically think about your patients.

The nature of ICU work allows one to truly understand the relationships among all the organs. Even though we separate the A/P into distinct systems, remember the body is all interconnected.

For example, why is a patient in shock? Is it a cardiac or septic shock pattern? As such, why might one pressor be better than another to maintain perfusion? The ICU Book by Dr. Paul Marino is a great resource for in-depth information.

Example ICU Patient Presentation Template

This is a shorthand template of the ICU patient presentation. Think of it as a starting point with some primers of what to cover in each section.

There is no ideal ICU presentation template, as it will vary between patients and even attendings. Adjust the template below to best fit your needs. It has the basics for each system and not all the bullets may apply.

Psst…don’t want to copy-paste this into a new doc? Scroll back up or click here to get the FREE download of the template for you to print and fill out on rotations!

One-liner:

Overnight Events:

A/P:

Neurological

o GCS ___

o Neuro/Mental status exam changes

o Sedation drips

o Pain medications, PRNs

o NSGY plans

Cardiovascular

o HR ___ MAPs ___ SBP range ___

o Pressors/Inotropes

o EKG/Echo

Pulmonary

o Intubated?

o Vent mode _____ RR ___ Vt ___ PEEP ___ FIO2 ___ O2 sat ___

o ABG (pH ___, CO2 ___, O2 ___, Bicarb ___)

o CXR

o Chest tube outputs

Gastrointestinal

o Diet

o BM

o LFTs

o Drains

o Bowel Reg

Genitourinary

o 24 hr I/Os

o Renal fxn (BMP)

Hematology

o CBC

o Blood products received

Infectious Disease

o WBC

o CRP

o Abxs

o Sources, Micro Cx

Endocrine

o Glucose

o Insulin

Musculoskeletal

o Ortho

o PT/OT

Prophylaxis

o SCD

o SQH

o PPI

Disposition

Abbreviations:

A/P: Assessment/Plan

GCS: Glasgow Coma Scale

PRN: Pro re nata 

NSGY: Neurosurgery

HR: Heart rate

MAP: Mean arterial pressure

SBP: Systolic blood pressure

EKG: Electrocardiogram

RR: Respiratory rate

Vt: Tidal volume

PEEP: Positive end expiratory pressure

FIO2: Fraction of inspired oxygen

ABG: Arterial blood gas

CXR: Chest X-ray

LFT: Liver function tests

BM: Bowel movements:

I/O: Ins/Outs

BMP: Basic metabolic panel

Fxn: Function

CBC: Complete blood count

WBC: White blood count

CRP: C-reactive protein

Abxs: Antibiotics

Cx: Cultures

PT: Physical therapy

OT: Occupational therapy

SCD: Sequential compression device

PPI: Proton pump inhibitor

SQH: Subcutaneous heparin

Final Thoughts on ICU Patient Presentations

I wish you the best of luck as you embark on your ICU rotation! This is one of the most fast-paced learning environments, so be a sponge and absorb as much as you can! Use this ICU patient presentation template, and you’ll be sure to give a great presentation that impresses your team and results in quality care for your patients.  

Looking for more (free!) content to help you through clinical rotations? Check out these other posts from Blueprint tutors on the Med School blog:

• How I Balanced My Clinical Rotations with Shelf Exam Studying
• How (and Why) to Use a Qbank to Prepare for USMLE Step 2
• How to Study For Shelf Exams: A Tutor’s Guide

Knowing how to deliver a patient presentation is one of the most important skills to learn on your journey to becoming a physician. After all, when you’re on a medical team, you’ll need to convey all the critical information about a patient in an organized manner without any gaps in knowledge transfer.

One big caveat: opinions about the correct way to present a patient are highly personal and everyone is slightly different. Additionally, there’s a lot of variation in presentations across specialties, and even for ICU vs floor patients.

My goal with this blog is to give you the most complete version of a patient presentation, so you can tailor your presentations to the preferences of your attending and team. So, think of what follows as a model for presenting any general patient.

This blog is tailored to general patient case presentations with a problems-based assessment and plan. Check out our ICU patient presentation template for an associated systems-based plan!

Here’s a breakdown of what goes into the typical patient presentation.

📘 FREE Download: Ultimate Patient Case Presentation Template

Want a customizable PDF to fill out during rotations? Submit the form and get the Ultimate Patient Case Presentation Template download sent right to your inbox…for FREE! 🤩

7 Ingredients for a Patient Case Presentation Template

1. The One-Liner

The one-liner is a succinct sentence that primes your listeners to the patient.

A typical format is: “[Patient name] is a [age] year-old [gender] with past medical history of [X] presenting with [Y].

2. The Chief Complaint

This is a very brief statement of the patient’s complaint in their own words. A common pitfall is when medical students say that the patient had a chief complaint of some medical condition (like cholecystitis) and the attending asks if the patient really used that word!

An example might be, “Patient has chief complaint of difficulty breathing while walking.”

3. History of Present Illness (HPI)

The goal of the HPI is to illustrate the story of the patient’s complaint. I remember when I first began medical school, I had a lot of trouble determining what was relevant and ended up giving a lot of extra details. Don’t worry if you have the same issue. With time, you’ll learn which details are important. 

The OPQRST Framework

In the beginning of your clinical experience, a helpful framework to use is OPQRST:

Onset

Describe when the issue started, and if it occurs during certain environmental or personal exposures.

Provocative

Report if there are any factors that make the pain better or worse. These can be broad, like noting their shortness of breath worsened when lying flat, or their symptoms resolved during rest. 

Quality

Relay how the patient describes their pain or associated symptoms. For example, does the patient have a burning versus a pressure sensation? Are they feeling weakness, stiffness, or pain?

Region/Location

Indicate where the pain is located and if it radiates anywhere.

Severity

Talk about how bad the pain is for the patient. Typically, a 0-10 pain scale is useful to provide some objective measure.

Timing

Discuss how long the pain lasts and how often it occurs.

A Case Study

While the OPQRST framework is great when starting out, it can be limiting.Let’s take an example where the patient is not experiencing pain and comes in with altered mental status along with diffuse jaundice of the skin and a history of chronic liver disease. You will find that certain sections of OPQRST do not apply.

In this event, the HPI is still a story, but with a different framework. Try to go in chronological order. Include relevant details like if there have been any changes in medications, diet, or bowel movements.

Pertinent Positive and Negative Symptoms

Regardless of the framework you use, the name of the game is pertinent positive and negative symptoms the patient is experiencing. I’d like to highlight the word “pertinent.” It’s less likely the patient’s chronic osteoarthritis and its management is related to their new onset shortness of breath, but it’s still important for knowing the patient’s complete medical picture. A better place to mention these details would be in the “Past Medical History” section, and reserve the HPI portion for more pertinent history.

As you become exposed to more illness scripts, experience will teach you which parts of the history are most helpful to state. Also, as you spend more time on the wards, you will pick up on which questions are relevant and important to ask during the patient interview. By painting a clear picture with pertinent positives and negatives during your presentation, the history will guide what may be higher or lower on the differential diagnosis.

Some other important components to add are the patient’s additional past medical/surgical history, family history, social history, medications, allergies, and immunizations.

The HEADSSS Method

Particularly, the social history is an important time to describe the patient as a complete person and understand how their life story may affect their present condition.

One way of organizing the social history is the HEADSSS method:

• Home living situation and relationships
• Education and employment
• Activities and hobbies
• Drug use (alcohol, tobacco, cocaine, etc.) Note frequency of use, and if applicable, be sure to add which types of alcohol consumption (like beer versus hard liquor) and forms of drug use.
• Sexual history (partners, STI history, pregnancy plans)
• Suicidality and depression
• Spiritual and religious history Again, there’s a lot of variation in presenting social history, so just follow the lead of your team. For example, it’s not always necessary/relevant to obtain a sexual history, so use your judgment of the situation.

4. Review of Symptoms

Oftentimes, most elements of this section are embedded within the HPI. If there are any additional symptoms not mentioned in the HPI, it’s appropriate to state them here.

5. Objective

Vital Signs

Some attendings love to hear all five vital signs: temperature, blood pressure (mean arterial pressure if applicable), heart rate, respiratory rate, and oxygen saturation. Others are happy with “afebrile and vital signs stable.” Just find out their preference and stick to that. 

Physical Exam 

This is one of the most important parts of the patient presentation for any specialty. It paints a picture of how the patient looks and can guide acute management like in the case of a rigid abdomen. As discussed in the HPI section, typically you should report pertinent positives and negatives.

When you’re starting out, your attending and team may prefer for you to report all findings as part of your learning. For example, pulmonary exam findings can be reported as: “Regular chest appearance. No abnormalities on palpation. Lungs resonant to percussion. Clear to auscultation bilaterally without crackles, rhonchi, or wheezing.”

Typically, you want to report the physical exams in a head to toe format: General Appearance, Mental Status, Neurologic, Eyes/Ears/Nose/Mouth/Neck, Cardiovascular, Pulmonary, Breast, Abdominal, Genitourinary, Musculoskeletal, and Skin. Depending on the situation, additional exams can be incorporated as applicable.

Labs

Now comes reporting pertinent positive and negative labs. Several labs are often drawn upon admission. It’s easy to fall into the trap of reading off all the labs and losing everyone’s attention. Here are some pieces of advice: 

You normally can’t go wrong sticking to abnormal lab values. 

One qualification is that for a patient with concern for acute coronary syndrome, reporting a normal troponin is essential. Also, stating the normalization of previously abnormal lab values like liver enzymes is important.

Demonstrate trends in lab values.

A lab value is just a single point in time and does not paint the full picture. For example, a hemoglobin of 10g/dL in a patient at 15g/dL the previous day is a lot more concerning than a patient who has been stable at 10g/dL for a week.

Try to avoid editorializing in this section.

Save your analysis of the labs for the assessment section. Again, this can be a point of personal preference. In my experience, the team typically wants the raw objective data in this section.

This is also a good place to state the ins and outs of your patient (if applicable). In some patients, these metrics are strictly recorded and are typically reported as total fluid in and out over the past day followed by the net fluid balance. For example, “1L in, 2L out, net -1L over the past 24 hours.”

6. Diagnostics/Imaging

Next, you’ll want to review any important diagnostic tests and imaging. For example, describe how the EKG and echo look in a patient presenting with chest pain or the abdominal CT scan in a patient with right lower quadrant abdominal pain.

Try to provide your own interpretation to develop your skills and then include the final impression. Also, report if a diagnostic test is still pending.

7. Assessment/Plan

This is the fun part where you get to use your critical thinking (aka doctor) skills! For the scope of this blog, we’ll review a problem-based plan.It’s helpful to begin with a summary statement that incorporates the one-liner, presenting issue(s)/diagnosis(es), and patient stability.

Then, go through all the problems relevant to the admission. You can impress your audience by casting a wide differential diagnosis and going through the elements of your patient presentation that support one diagnosis over another. Following your assessment, try to suggest a management plan. In a patient with congestive heart failure exacerbation, initiating a diuresis regimen and measuring strict ins/outs are good starting points.

You may even suggest a follow-up on their latest ejection fraction with an echo and check if they’re on guideline-directed medical therapy. Again, with more time on the clinical wards you’ll start to pick up on what management plan to suggest.

One pointer is to talk about all relevant problems, not just the presenting issue. For example, a patient with diabetes may need to be put on a sliding scale insulin regimen or another patient may require physical/occupational therapy. Just try to stay organized and be comprehensive.

A Note About Patient Presentation Skills

When you’re doing your first patient presentations, it’s common to feel nervous. There may be a lot of “uhs” and “ums.”

Here’s the good news: you don’t have to be perfect! You just need to make a good faith attempt and keep on going with the presentation.

With time, your confidence will build. Practice your fluency in the mirror when you have a chance. No one was born knowing medicine and everyone has gone through the same stages of learning you are!

Practice your presentation a couple times before you present to the team if you have time. Pull a resident aside if they have the bandwidth to make sure you have all the information you need. 

One big piece of advice: NEVER LIE. If you don’t know a specific detail, it’s okay to say, “I’m not sure, but I can look that up.” Someone on your team can usually retrieve the information while you continue on with your presentation.

Example Patient Case Presentation Template

Here’s a blank patient case presentation template that may come in handy. You can adapt it to best fit your needs. 

Psst…don’t want to copy-paste this into a new doc? Scroll back up or click here to get the FREE download of the template for you to print and fill out on rotations!

One-Liner: 

Chief Complaint: 

History of Present Illness: 

Past Medical History:

Past Surgical History:

Family History:

Social History:

Medications:

Allergies:

Immunizations: 

ROS: 

Objective: 

Vital Signs:

Temp ___

BP ___ /___

HR ___

RR ___

O2 sat ___ 

Physical Exam:

General Appearance:

Mental Status:

Neurological:

Eyes, Ears, Nose, Mouth, and Neck:

Cardiovascular:

Pulmonary:

Breast:

Abdominal:

Genitourinary:

Musculoskeletal:

Skin:

Labs:

Most Recent Labs:

Previous Labs:

Diagnostics/Imaging:

Study:

Impression/Interpretation:

Assessment/Plan:

One-line summary:

#Problem 1:

Assessment:

Plan:

#Problem 2:

Assessment:

Plan:

Looking for some help studying your shelf/Step 2 studying with clinical rotations? Try our combined Step 2 & Shelf Exams Qbank with 5,500 practice questions—free for 7 days!

Final Thoughts on Patient Presentations

I hope this post demystified the patient presentation for you. Be sure to stay organized in your delivery and be flexible with the specifications your team may provide. Something I’d like to highlight is that you may need to tailor the presentation to the specialty you’re on. For example, on OB/GYN, it’s important to include a pregnancy history.

Nonetheless, the aforementioned template should set you up for success from a broad overview perspective. Stay tuned for my next post on how to give an ICU patient presentation. And if you’d like me to address any other topics in a blog, write to me at neelesh.bagrodia@blueprintprep.com!

Looking for more (free!) content to help you through clinical rotations? Check out these other posts from Blueprint tutors on the Med School blog:

• How I Balanced My Clinical Rotations with Shelf Exam Studying
• How (and Why) to Use a Qbank to Prepare for USMLE Step 2
• How to Study For Shelf Exams: A Tutor’s Guide

As you progress through medical school and the structure of your educational curriculum evolves, how you learn will also change. The most dramatic transition happens when you start your clinical rotations. In the process, you move from classroom-based or online learning with content developed by your medical school (e.g., lectures, online modules, and labs) to more experiential learning immersed in patient care.

This entails a year-long series of blocks, each comprehensively covering specific areas of healthcare to teach you how providers in these fields practice. Notably, exams remain built into the curriculum, but in contrast to preclinical tests developed by your school, these are often standardized “shelf exams” produced by the National Board of Medical Examiners (NBME).

To make sure you’re as prepared as possible for your clerkships, read on to learn more about what shelf exams are and, even more importantly, how to study for shelf exams.

What are shelf exams? 

Most of your rotations for clerkship year will culminate in a shelf exam. Typically, these exams have 110 multiple-choice questions. Each question has a single best answer and you’ll have 165 minutes to complete the exam. 

What is tested on shelf exams?

In contrast to the questions on the United States Medical Licensing Exam (USMLE) Step 1, shelf exams focus much more on the care of patients, including how to diagnose and treat diseases. You should expect to be tested on the identification of the next steps in management, utilization of appropriate and cost-effective diagnostic tests, and selection of correct pharmacotherapy. 

In general, the questions are very reflective of the USMLE Step 2 CK. Many have likened Step 2 CK to a sampling of questions from all the shelf exams consolidated into one test.

Wondering if you’re on track with your shelf exam prep? Take our FREE quiz from our Blueprint experts to find out!

What topics are on a shelf exam?

Intuitively, the content of each exam will relate to the field of medicine or surgery you just did a rotation in.For more specific details, the NBME publishes a content outline online that provides a breakdown of the different items tested on each exam. As an example, the outline for the internal medicine shelf exam can be found here. 

It’s important to understand that material can overlap across multiple shelf exams. An important example is the surgical shelf exam, which tends to focus less on procedures or techniques and more on the medical management of surgical patients (e.g., diagnosing postoperative fever or recognizing peritonitis). 

Other examples include concepts at the intersection of neurology and psychiatry or internal medicine and pediatrics. This means that, while earlier shelf exams may be inherently more challenging, shelf exams become easier as you see recurring concepts across specialties.

Which resources should I use to study for shelf exams?

The learning you gain from the rotation itself will go far in your exam preparation. However, these exams are wide-ranging enough that you won’t be exposed to everything that might be tested, so you should supplement your “on-the-job” education with independent study. 

The best advice on how to study for shelf exams? Use Qbanks! 

At the core of your approach to every shelf exam should be a good question bank like Blueprint’s combined Step 2 & Shelf Qbank. This Qbank is tailored to the NBME content outline and emphasizes the high-yield content most likely to appear on the exam in a multiple-choice format that makes the learning active and effective. You can categorize practice questions by shelf exam, while also using it to prepare for Step 2 CK!

Study like you mean it with the new Step 2 & Shelf Exams Qbank, the most representative NBME Qbank with test-like questions to help you pass USMLE Step 2 CK and all your Shelf exams. Get started with 7-day FREE access to 5,500 questions!

What else do I need to know about how to study for shelf exams? 

Beyond using a relevant Qbank, the resources you use will depend on the rotation, as different resources are effective for different shelf exams. Some of our best recommendations are summarized below.

1. Internal Medicine: “Step-Up to Medicine”; OnlineMedEd
2. Surgery: “Dr. Pestana’s Surgery Notes”; “Surgical Recall”
3. Pediatrics: “Blueprints Pediatrics”; “Case Files Pediatrics”
4. Family Medicine: “Case Files Family Medicine”
5. Obstetrics and Gynecology: “Blueprints Obstetrics and Gynecology”; APGO uWISE Program
6. Psychiatry: “First Aid for the Psychiatry Clerkship”; “Case Files Psychiatry”
7. Neurology: “Blueprints Neurology”

Remember: shelf exams are still standardized exams, so good test-taking skills will maximize your performance. You should use techniques such as reviewing the question before reading the vignette and the process of elimination.

As you study, you will pick up quick high-yield clinical pearls like avoiding a computed tomography scan for a hemodynamically unstable patient that will allow you to work through patient management questions quickly. Again, practice makes perfect, so make sure you’re building plenty of practice questions into your study plan.

How do I find time to study for shelf exams?

Another aspect of your clerkship year that is different from your preclinical experience is that you will have significantly less time for studying after a long workday in the hospital. To that end, you want to maximize efficiency in how you construct your study schedule. As with every plan, you should determine upfront how much you want to get done by exam day. 

How can I make a study schedule that I’ll stick to? 

First, consider which materials you will use—you can consult the list above for a starting point. You then simply divide how much time it will take to work through those resources by the number of days before the test to get a sense of what you need to finish daily.

Importantly, you must build in plenty of flexibility for catch-up days, practice exams, and days off.

First off, you may have to work extra hours at the hospital sometimes, and consequently not have much time to study once you get home. Furthermore, you should consider spending a day doing a practice NBME shelf exam or two. These provide an idea of what the exam format and questions will entail and can be purchased here for a small fee.

Finally, it is most important that you schedule days off whenever possible to return to work in the clinic or hospital or to your studying feeling refreshed and recharged.

A great resource that can help you keep track of everything is Blueprint’s Med School Study Planner. It takes all the guesswork out of how much time resources require and constructs a reasonable study plan leading up to your exam day in a user-friendly interface. 

Thousands of medical students use Blueprint’s Med School Study Planner to save hours of planning time, see exactly what to do each day, and ace their med school exams. Get unlimited access today!

The bottom line: Knowing how to study for shelf exams paves the way for Step 2 CK!

This recipe for success on shelf exams will pay off again when it’s time to study for and take Step 2 CK, an exam that borrows questions and concepts from each of the shelf exams and incorporates them into one test. Recall that Step 2 CK will still assign a three-digit score to your performance and know that score has been increasingly important in the residency application process now that Step 1 is a pass/fail exam.

Your study plan for Step 2 CK will center again on a quality question bank in conjunction with the same ancillary resources listed above for each of the shelf exams. Therefore, heading into your clerkship year with a good plan of how you will prepare for shelf exams will pave the way for you to do well on almost all the standardized tests you will have in medical school thereafter, including Step 2 CK.

Further Reading

Looking for more (free!) content from Blueprint tutors? Check out these other posts on the Med School blog:

• Which Are the Hardest Shelf Exams?
• How I Balanced My Clinical Rotations with Shelf Exam Studying
• Best Shelf Exam Study Resources: A Comparison & Breakdown

Scrubs is consistently described as the most accurate (and fun) medical show out there. If you’re a fan of the series, then kick back and take this quiz to find out which character you mirror the most during your clinical rotations!

Looking for help studying for shelf exams during your rotations? Meet the combined Step 2 & Shelf Exams Qbank with 5,500 practice questions that most closely match what you’ll see on your USMLE Step 2 and all of your shelf exams. Get started with 7-day FREE access!

Now that you’ve figured out your Scrubs avatar, why not dig a little deeper to figure out how they (you) could make clinical rotations easier? Check out these great posts to ensure your shifts aren’t as stressful as a TV medical drama:

• How I Balanced My Clinical Rotations with Shelf Exam Studying
• How (and Why) to Use a Qbank to Prepare for USMLE Step 2
• How to Study For Shelf Exams: A Tutor’s Guide

Image Credits: NBC and ABC

I was very excited for my first day in an operating room, but woefully unprepared for what to expect. Part of that was not understanding the flow of an OR and worrying I would embarrass myself in the unfamiliar environment. (For a run down on what to expect, I recommend you read my last article about how to navigate your first time in the OR!) 

The other part of my anxiety was not knowing how I would react to some of the unfamiliar body fluids and smells unique to surgery. The morning of the case I neglected to eat or drink, worried I would need to use the restroom. Unfortunately, that led to my lightheadedness and tunnel vision during the case. Instead of suturing at the end, I was in the breakroom drinking juice and eating crackers—and feeling embarrassed. 

Over the next six weeks of the rotation, I came to enjoy much more complex, long, and bloody cases without any of the issues I had been ashamed of on my first day. I credit my improvement to developing a lot of the tactics below which kept my mind and body in check during long hours in the OR. 

Here are some tips to keep you on your feet (literally)!

Studying for your shelf exams and Step 2? We’ve got you covered. Meet the new combined Step 2 & Shelf Exams Qbank with 5,000 practice questions that most closely match what you’ll see on your MS3 exams. Get started with 7-day FREE access!

1. Start slow.

If you have the option, try to start with easier and shorter cases. That way, you can hydrate without worrying you’ll be stuck in a case with a full bladder for hours. (More on strategies for hydrating in a bit.) 

Since easier and shorter cases tend to be less bloody, you won’t get freaked out by a particularly messy surgery the first time you’re in the OR. By starting off with something easy, you can practice scrubbing and get to know the structure of the OR without worrying about much else.

Recommended Starter Cases

The best cases to start with are laparoscopic cases (i.e., not open abdomen) because you are viewing everything through a camera rather than staring right into someone’s guts or bloody wounds. (If you’re lucky, they’ll let you drive the camera, which is pretty cool.) 

Good starter cases:

1. Laparoscopic or robotic Ob/Gyn surgeries like hysterectomies, tubal ligations, and myomectomies
2. Quick general surgery cases like lipoma or skin cancer removal, hernia repairs, or laparoscopic cholecystectomies or appendectomies
3. Straightforward, non-bloody urology cases like hydrocele repair or penile implant placement

Avoid these starter cases: 

1. C-sections (very bloody)
2. Amputations and any orthopedic surgery involving a hammer or saw (very bloody and somewhat barbaric)
3. Surgical oncology cases (they’re cool, but loooong)

2. Eat well.

I made the mistake of not eating before my first case because I was worried I’d get queasy. I do NOT recommend doing that! You don’t need to have a huge breakfast (I would recommend against this also) but don’t fast before reporting to the OR. 

As for what to eat, I found that protein bars and especially dried fruit worked great and kept my energy up during cases. Remember that you may have a few of them each day, so keep some quick snacks in the breakroom that you can eat between surgeries.

3. Stay hydrated.

This is very tricky, because you have to strike a balance between being hydrated enough to last the whole case but not so hydrated that your bladder is about to burst. 

My best recommendation is to hydrate a lot in the afternoon and evening. When you’re done with cases for the day, commit to drinking a lot so that you wake up the next day hydrated without having to take in a lot of fluids before the case.

If you’re a coffee drinker, hydration can be especially tricky. I was very careful not to drink coffee before cases. It’s best to seek out other sources of caffeine, so you don’t need a bathroom break during surgery.

4. Dress wisely.

Overheating is the easiest way to get woozy and wind up on the floor. For this reason, I don’t recommend wearing an undershirt beneath your scrubs. While the OR may seem cold in just your scrubs, you’ll be surprised how much hotter it is once you’re in a full gown, mask, bonnet, and two pairs of gloves. 

Additionally, I recommend tying your mask loosely around your face. Having good airflow and not feeling suffocated by your own breathing goes a long way. (If you wear glasses, be sure to tape the top of your mask so they don’t don’t fog up from your breath.)

5. Flex your calves.

Fainting, called “vasovagal” syncope, is in part caused by a drop in blood pressure, which reduces the amount of blood that is supplied to the brain. The body adapts by forcing you to lie l on the ground so the heart doesn’t need to pump against gravity to get blood to your head. 

One way you can try to counteract a drop in blood pressure is by squeezing blood from your lower body so that it moves upwards. For example, bouncing on the balls of your feet squeezes your calf muscles against the veins which returns blood to the heart. Alternatively, clenching/unclenching your butt can also achieve some blood return. 

These little exercises not only allow you to physiologically overcome the fainting episode, they can help relieve the anxiety that often accompanies pre-syncopal symptoms.

6. Stay calm. 

This is easier said than done, but if you’re starting to feel hot, dizzy, and worried you may pass out, start taking some deep breaths. 

Look away from the surgical field, especially if you think the blood or other fluids are making you uneasy. Looking at the vitals monitor is a good way to appear engaged while giving yourself a breather.

7. Step back from the table. 

If you really feel like you’re close to passing out and none of the usual tricks are working, take a step back from the operating table. The worst thing you can do is faint forward into a sterile field and end up in the patient. 

If you step straight back, you’re not breaking the sterile field and you can come back to the table when you’re feeling better as long as you don’t touch anything. A sharp circulating nurse may get to you in time and give you a stool to sit on so you can take a few minutes and collect yourself. If this happens, just relax, and return to the table when you’re ready. 

While having to step back may feel embarrassing at the time, it will actually earn you a lot of respect from your colleagues in the OR. Your self-awareness, poise, preservation of the sterile field, and ability to put the patient’s safety above all else (including your ego) are all admirable. Everyone will think highly of you because of how you handled the situation.

Further Reading

Humans weren’t built to see inside each other. Remember that surgery is fundamentally strange and gross so you shouldn’t feel embarrassed if certain things make you queasy. Everyone has different things that make their stomach turn, including surgeons. Be patient and graceful with yourself—you’re doing a lot on little sleep! 

Keep these tips in mind and I’m sure you’ll excel at your surgical clerkship—or at least survive it so you can move on to your true passion.

For more (free!) content from Blueprint tutors to help you during your clinical rotations, check out these other posts on the Med School blog:

• How I Balanced My Clinical Rotations with Shelf Exam Studying
• How to Introduce Yourself to Patients During Rotations
• Best Shelf Exam Study Resources: A Comparison & Breakdown

Scrub up! If these words strike fear into your heart, you’re in good company. For most medical students, the first time they enter an operating room (OR) is during third-year clerkships. Nothing will quite prepare you for that moment, but some familiarity with the different roles, order of operations, etiquette, and expectations for medical students in the OR will help calm your nerves. 

To help you get ready for your first day in the OR, we’ll go through what you can expect from start to finish. While it’s going to take some time to adjust to the unique environment of the OR, what follows can certainly help you navigate day one. So get ready, get prepped, and let’s walk through a day in the life of an MS3 on their first day of surgery rotation.

How to Crush Your First Day in the OR: Tips for Handling it From Start to Finish

Pre-Rounding & Patient Presentations

To get ready for rounds, you’ll need to arrive at the hospital very early on your first day of the surgery rotation. Unfortunately, this is likely to be around 4 am. Since surgeons are busy in the OR all day, they must round on patients before the first cases start at 7 am. For you, this means that you must pre-round and prepare your patient presentations in time for 5 am or 6 am.

“SOAP” Format Presentation

The good thing is that surgical rounds are short and sweet. Expect to do your usual “SOAP” format presentation with special attention to the following:

“S” – Subjective information about the patient 

Is the patient nauseous or in severe pain? Some postoperative pain or site tenderness is normal, but pain out of proportion to what you’d expect for the procedure can indicate a complication like internal bleeding, perforation, abscess formation, compartment syndrome, etc.

“O” – Objective information about the patient

This includes:

Vitals overnight

Fevers and tachycardia can represent normal postoperative phenomena or something more sinister like an infection. A dropping blood pressure could represent dehydration or, more worrisome, shock.

Basic labs

Point out trends like a rising creatinine/BUN meaning the patient may require fluids, a rising white blood cell count hinting at infection, or electrolyte abnormalities suggesting malnutrition or a stunned bowel with poor absorption (ileus).

“A” – Assessment 

Mention the patient’s name, age, hospital day, postoperative day, procedure (e.g., “status post cholecystectomy”) and your general assessment, i.e., do you think they’re improving, stable, or worsening?

“P” – Plan 

This is the most difficult part for every medical student but it’s also the most fun because it’s where you flex your doctor muscles. 

Low-hanging fruit for plans on a surgical service include:

Getting them out of bed/ambulating

Gone are the days when patients are put on bedrest after surgery. New research indicates that getting out of bed as soon as possible and moving around speeds up the healing process.

Advancing their diet

Patients will advance from a diet of clear liquids, to full liquids, to soft foods, and finally to a regular diet. They may need changes to their tube feeds or IV feeds (called TPN, or total parenteral nutrition).

Stopping or starting IV fluids

See if the patient is dry or puffy and take the appropriate steps. 

Determining if they need more surgery

Patients with severe infection or burns may need repeat debridement or grafting.

Determining if other specialists need to get involved

Common consultants for surgical teams include infectious disease, medicine, and other surgical subspecialists in the area that was operated on. This is particularly true of transplant or surgical oncology cases which tend to be very interdisciplinary. 

Discussing barriers to disposition

What’s keeping them from getting out of the ICU, step-down unit, or home altogether? Often it’s eating normally, passing gas (“flatus”), bowel movements, or having pain/nausea that requires IV medications only available in the hospital. They may also still require wound care dressings or a wound vac with plans to continue this care outpatient. 

You’ll start to pick up on patterns as the days and weeks go on, but this is a good list to start!

Feeling uneasy about being in the OR? We’ve got you covered with these guides:
😵‍💫 7 Tips to Help You Avoid Fainting in the OR
😷 How to Rock Your Surgery Rotation (and Live to Tell the Tale)

Pre-Op & Meeting With Patients

Congratulations! You’ve survived rapid-fire surgical rounds. Now it’s time to get to pre-op and meet your patients. 

You should introduce yourself to them in the pre-op area. Let the patient know your role, that you’ll be observing their case, and that you’re happy to answer any questions to the best of your ability. As a medical student, you have a real opportunity here to make a difference for patients who are anxious before surgery. You can be a source of reassurance and familiarity before they get rolled back to the OR.

🤝 Check out this blog post for more detailed instructions about how to introduce yourself to patients during rotations!

The anesthesiologist will also come in to explain their role and may give some anxiolytics or sedatives before the patient is rolled back to the OR on a stretcher.

Welcome to the OR!

Then you’ll accompany your patient back to the OR. Make sure you have on hospital scrubs, booties over your shoes (or alternatively, OR clogs), your mask, and a hair cap. You won’t be let into the OR suites without your full personal protective equipment (PPE) in place. Hopefully, you ditched the short white coat back in the workroom. 

Once the patient is in the OR, things will start happening around you. A well-run OR is a wonderful thing to witness because everyone has a very defined role. As a medical student who often feels in the way with a very amorphous job, you may grow to like the mechanical feel of the OR.

Get to Know the Team

Some of the masked faces you’ll encounter in the OR include: 

The circulating nurse 

The circulating nurse person will stay unscrubbed for the entire procedure. Since they are not “sterile,” they can’t touch anything that’s sterile. This frees them up to do a variety of tasks during the case, which may include getting extra supplies, recording events in the computer, adjusting lights/music (surgeons are particular about their playlists), calling the blood bank/pathology lab/micro lab, etc., returning pages coming in for the residents/attending, and many other roles.

The scrub tech 

The scrub tech is the opposite of the circulating nurse. They’re responsible for maintaining the sterile field and policing all the sterile people. They’ll help you get scrubbed in when the time comes and will be watching you very closely during the case to ensure you don’t break the sterile field.

By the way, the “sterile field” refers to anything that has been cleaned and draped with a sterile cloth or tarp or has come from a sterile package. This includes certain equipment in the room, the tools used during surgery, the surgeon gowns/gloves, and of course, the patient!

The anesthesiologist

Once the patient is on the stretcher and sedated in the OR, everyone gets to work. The anesthesiologist or nurse anesthetist inserts whatever IV access they need during surgery, which may include a central line or peripheral lines. A case that’s expected to be bloody or require pressors may involve more points of access. They’ll likely insert an arterial line which is an invasive way to monitor the blood pressure constantly via a catheter in the radial artery of the wrist.

Anesthesiologists are NOT scrubbed in and sit behind a curtain at the patient’s head. It’s the anesthesiologist’s job to keep the patient safe during surgery—they constantly monitor the patient’s vitals and sedation state so they can make adjustments. They have the authority to cancel a case if they don’t feel that a patient can be safely extubated, their morning labs are worrisome, or something else concerns them. 

Likewise, if a patient codes or starts having a complication, the anesthesiologist runs the resuscitation effort. There are even branches of anesthesiology like obstetrics anesthesia and cardiac anesthesia which require special training and expertise to handle complex, high-risk cases.

Time to Scrub Up!

While everyone is setting up, make sure you keep track of what the resident is doing so you can take cues from them. When the resident steps outside the OR to “scrub up” at the sinks, you should too. Pay close attention to how they sanitize the fingernails and clean all the way up the arm. There’s also a particular technique to drying your hands with a towel to ensure you’re only touching the clean towel. I highly recommend watching a few YouTube videos on the process before you start your rotation.

When you return to the OR, make sure you don’t touch anything with your newly cleaned hands and arms. The scrub tech will assist you in finishing drying off, putting on sterile gloves, and getting your sterile gown on. At any point in this process you may break the sterile field, and they may ask you to rescrub or put on an extra sterile sleeve. If this happens, don’t freak out. It’s okay! It’s all in the best interest of the patient and everyone—including the attending surgeon—has broken the sterile field and been asked by the scrub tech to reclean or drape.

Preparing for Questions

Now it’s finally time for the case! Hopefully you prepared the night before or in pre-op for what you’ll be seeing. Surgeons are notorious for asking questions, often called “pimping” during cases. 

It’s good to acquire some basic knowledge, but overall you shouldn’t stress too much about this. Your priority as a student is to take good care of your assigned patients, work well with the residents, and do well on your surgery shelf exam. If you don’t know the answer to an esoteric question about a procedure the surgeon has been performing for decades, don’t let it rattle you.

Still, you should study some basics commensurate with your level of training. For example, I recommend reading the patient’s chart to see what surgeries they’ve had in the past and what workup they’ve had so far for their condition. You should also research the procedure itself, the steps involved, the indication, and the recovery. 

Finally, be sure you study the anatomy of the area itself. The surgeon may ask you about any of this, especially the anatomy, so it’s best to be prepared. You also will get much more out of the experience if you have some background on what’s going on.

Looking for extra help while studying for your shelf exams? Meet the new combined Step 2 & Shelf Exams Qbank with 5,500+ practice questions that most closely match what you’ll see on your USMLE Step 2 and all of your shelf exams. Get started with 7-day FREE access!

What You’ll Be Doing 

During the case, you may be asked to do any number of things, such as retracting skin so the field is easier to see or suctioning blood or fluid out of it. At the end of the case, the resident will typically close the wound by suturing the patient. Many residents will even allow the medical student to suture the patient closed, especially if it’s a laparoscopic surgery where there are few sutures to be thrown. 

Try to practice before your rotation! You can buy a practice suturing kit online that comes with tools, suturing, and silicone fake skin. Self-studying for this is very easy, since there are plenty of YouTube videos on how to throw all sorts of sutures. After a while, it’ll be a rote activity you can practice while watching TV. You’ll be glad you worked out the suturing kinks in the comfort of your living room before everyone is watching at the end of the case. 

A couple more things before we wrap up: I recommend you start out with shorter cases if possible so you can get used to being in the OR. It’s also a good idea to have a snack or use the bathroom before a case begins. After all, once you’re “scrubbed in,” you’re committed to it. If you really need to leave the OR because you’re starving or have to use the restroom, you may not be able to scrub back in. 

Be sure to speak with your clerkship director before the rotation if you have any extenuating circumstances like diabetes, pregnancy, IBS or any other reason why standing for several hours without food or a bathroom break isn’t doable so accommodations can be made. It’s also wise to speak with the residents and attending physician before each case so they know you’ll be leaving at some point.

Further Reading

You’re not alone if you’re a bit worried about starting your surgery rotation. But you’ve come this far, and you have what it takes to succeed! Follow these tips for handling your rounds, pre-op, and what to do once you get into the OR and you’ll hit the ground running. 

Good luck, and don’t get nervous when someone says “scrub up.” Now you know what to expect! 

For more (free!) content from Blueprint tutors to help you during your clinical rotations, check out these other posts on the Med School blog:

• How I Balanced My Clinical Rotations with Shelf Exam Studying
• How to Honor Your Clerkships
• Clerkship Pitfalls: What Is Situational Awareness in Healthcare?

During my third year of medical school, the first half of my general surgery clerkship was spent on the hepatobiliary and transplant surgery service.

One day, as we were completing the running subcuticular stitch on skin after a Whipple procedure, the fellow looked up at me and asked, “Are you interested in going on a liver procurement tonight?” I responded with a resounding affirmation.

Of course, the procurement meant I wouldn’t be doing any Qbank questions that night. But in retrospect, it was a small sacrifice considering the ensuing experience became one of the reasons I fell in love with surgery and decided to pursue a career in it.

In the end, this decision didn’t impact my performance on the shelf exam because I had a solid study plan. The moral of the story is, while finding a balance during third year can be difficult, it can be done! And I hope over the course of this article, my experiences and perspective can aid you in excelling on your shelf exams while also putting your best foot forward on the wards.

Let’s begin with a brief reminder of why shelf exams matter, and why finding the right balance between your rotations and preparing for them is a huge part of what third year is all about.

Why Shelf Exam Prep Matters

So, why are shelf exams so important, and why do you need to spend time preparing for them during third year? Well, many medical schools incorporate your shelf exam score into calculations for your final grade on the clerkship, which could be the difference between honors, high pass, and pass. For those with a pass/fail grading system during clinical rotations, shelf exams are still important as they can be predictive of Step 2 scores, which are all the more important in a pass/fail Step 1 world. 

Shelf Exam Prep and Wards: Feel the Synergy!

Your shelf exams are a big deal, but the best way to approach third year is to view performance on the wards and preparation for shelf exams as synergistic, not as competing interests.

For example, my first day of third year was on internal medicine and we had a patient with altered mental status get admitted at 5:30 pm. It was up to me if I wanted to stay or go home. After deciding to write the H&P for the patient, the differential diagnosis for altered mental status has been ingrained in my mind ever since—in a way I don’t think a textbook or question bank could have taught me. 

This wasn’t the exception to the rule. During my third year, I often found that learning from an actual patient was far more impactful than anything I could read in a book. Acclimating to this style of learning as opposed to the traditional classroom lectures of preclinical years is one of the most important things that happens during wards. In fact, some of the greatest clinical pearls I gathered over the years were quick tidbits passed during rounds or while at the patient’s bedside. This kind of learning isn’t something that stands in the way of traditional shelf exam prep, it’s actually a great way to complement it.

Some Great Shelf Exam Study Materials 

So, imagine you’re coming home from a rewarding day at the hospital and you’re asking yourself “what should I study?” I found that using a few resources to their fullest potential set me up for the most success.

For every one of my rotations, I completed all the relevant Qbank questions and AnKing cards. I also supplemented this by watching Dr. High Yield, Emma Holliday, and OnlineMedEd videos (they were free when I was a 3rd year).

However, this was what worked for me and it is likely that a different combination of resources may be most effective for you. I have friends who despised Anki and learned best by listening to Divine Intervention during their commute and reading books like Case Files and StepUp. Some of my classmates opted to only complete a portion of the Qbank questions for each clerkship.

Obviously, there’s a lot of ways to study for a shelf exam. It may take a few rotations to find the resources that you like the most and settle into your studying groove. It certainly did for me. Don’t fret—be ok with switching things up if a certain routine is not working for you.

Wondering if you’re on track with your shelf exam prep? Take our FREE quiz from our Blueprint experts to find out!

Creating a Shelf Exam Study Schedule

Another big aspect of studying for shelf exams while on rotations is creating a study schedule that works for you. For example, while some of my colleagues preferred to start their Qbank questions towards the second half of rotation, I am a big fan of doing a few reps everyday leading up to race day.

All my rotations were six weeks in length, with the shelf exam towards the end of the final week. At the beginning of the rotation, I would divide the Qbank questions over the first 5 weeks and leave the final stretch for NBME practice exams and review. I liked this strategy because it divided shelf studying into daily bite-sized amounts that were doable for me. Most days, I had to do 20-30 Qbank questions at home which was manageable. If I ever stayed extra late at the hospital and couldn’t do the day’s questions, I would distribute them over other days.

Studying During Rotations

Additionally, keep in mind that during rotations, you don’t need to wait until you get home to start studying. In my case, I often had downtime when I was done pre-rounding, or even sometimes after lunch. I would use this time to knock out some Anki cards on my phone. Then, when I got home, I just finished what was left.

This approach worked really well for me, but a different approach might be best for you. Also, if the team doesn’t need any help from you, it’s ok to ask if you can use the time to study. They may even do a quick chalk talk on a challenging topic for you! This way, when I got home, I often completed my Anki cards or just had a small portion left.

Again, this method worked very well for me, but a different approach might be best for you. Some of my colleagues would prefer to start their Qbank questions towards the second half of the rotation. There’s a lot of ways to create your study schedule, just make sure you tailor it to your needs. Also, be sure to schedule some catch up and break days into your study plan, as life does not stop during clerkship year.

If you need some help setting up a schedule, I recommend checking out Blueprint’s Med School Study Planner, which automatically schedules your shelf exam studying for you throughout your rotation!

Shelf Exam Prep When You’re Tired After a day at the Hospital

Now let’s go over a common situation. You have come home from a long day at the hospital and are completely drained. The last thing you want to do is type your Qbank URL into your search bar or fire up Anki. You could try to do more passive studying and watch a video or listen to a podcast while cooking dinner. If that’s still too taxing, then take the night off and focus on your well-being. The third year of medical school is like a marathon, so it’s best to take the time to refuel and check in with your support system.

Further Reading

I extend my heartfelt congratulations on entering this exciting period of your medical school journey and I am rooting for you. Remember, third year is about finding a shelf exam prep and rotations balance that works. If you’re having trouble striking this balance, or are interested in medical school tutoring, please contact the Blueprint team. I’d be more than happy to schedule a session with you!

Looking for more (free!) shelf exam and clinical rotation tips from Blueprint tutors? Find more on the Med School blog:

• How to Study For Shelf Exams: A Tutor’s Guide
• Best Shelf Exam Study Resources: A Comparison & Breakdown
• How to Honor Your Clerkships

When I was preparing for USMLE Step 1, I distinctly remember my anxiety building as the exam approached. This anxiety, though unpleasant, was met and balanced by another powerful emotion: excitement. I was excited by the prospect of finally putting the exam in my rearview mirror, and by the idea that, once it was over with, I’d be in the hospitals, learning from and helping to treat patients. After all, being a doctor is really all about getting to M3, isn’t it? Working with patients is what brought many of us into this field, so it’s certainly exhilarating to finally reach the transition from M2 to M3. 

And yet for all the excitement, the transition from school work to clinical practice is not without difficulty. There are definitely some bumps along the way. Here are some changes, pitfalls, and tips to keep in mind as you move from M2 to M3!

Transition From M2 to M3: 4 Changes, 3 Pitfalls, and 2 Tips

4 Changes to Make

1. Time 

During M3, most of your time will be spent in a hospital or clinic and in direct contact with patients. There will be an immediate realization that your time is not under your control, and for the most part, it isn’t. As you’ll soon discover, the time requirement itself is much more intensive and much less predictable than during M2. Thus, your study plans and dinner plans will sometimes be in flux. (As a side note: Blueprint’s Cram Fighter is an excellent tool to help structure your study plan and with its rebalancing function, it’s the perfect resource to help you be adaptable.)

2. Grades 

As a M3, your clinical rotations are evaluated by shelf exams, and clinical evaluations from your preceptors. You will spend most of your time helping take care of patients and only a minority of your time will be dedicated to practice questions, video lectures, and so on. You will have to take the initiative in your education by learning and participating at the hospital, and also integrate studying that is specific for the upcoming shelf exam. The ‘on-the-job’ learning is absolutely relevant to your growth as a clinician, but it alone is not enough to crush the exams.

3. The Stakes 

 As an M3, you’re not alone in the hospital and you’re not the sole decision-maker on really any aspect of your patient’s care. The goal is that you get one step closer to being able to make those decisions. As an M2, the worst that could happen is UWorld puts an X on your answer choice. While the stakes as an M3 are shielded by the attending/resident on your care team, they soon won’t be.

I would advise you to take advantage of this time! It’s truly an invaluable learning environment to be able to make your own independent assessment and plan for a patient without putting the patient at risk. You only get so many chances to learn in this environment before a mistake has real consequences. This is a major transition of responsibility during these clinical years.

4. Mental Health

The transition to M3 comes with a set of new and unique stressors. Difficult days become deeper than a poor exam performance or bad block of practice questions. Being involved and moreover, invested, in your patient’s care and their lives is truly rewarding. However, there are times when the outcomes don’t pan out in our favor, and those days can be truly difficult. When they come, talk to someone and debrief about adverse experiences. Whether it’s a peer, a resident, a faculty mentor, or a close friend, remember you’re not alone. 

3 Pitfalls to Look Out for 

1. Being Present, but not Active

Don’t assume that your presence is enough to learn the information necessary to grow clinically or to pass the shelf exam. You need to be proactive and secure learning opportunities. Some resident physicians and attendings are stellar educators, and some are not.

During M3, I learned a lot about patient care, clinical decision-making, and procedural skills, but even the best educators spent little time teaching information specific to the shelf exam. The assumption from most preceptors was that shelf studying is done on your own time, between clinical obligations, or at home. 

Additionally, while some preceptors will put you in the right place at the right time to secure a learning opportunity, not all of them will. If you want to learn more about something, or if you want to help with a procedure, find a time when your team has a moment to relax, and ask. 

2. Procrastination

Don’t start your shelf studying on week two, week four, or week eight. Start on day 0. Make a plan, distribute the workload, and execute. If you start halfway through the rotation, you won’t be prepared enough to learn in the clinical setting and participate in your patient’s care, and you’ll have half the time to fine-tune your learning and identify knowledge gaps with residents and attendings nearby. 

3. It’s Real Life

 Another common pitfall is bringing a preclinical mindset into the hospital. Recognize that learning from patients is very different than learning from a Qbank question or a flashcard. The medical knowledge you have now must be applied to patients. I recommend paying close attention to the orders your residents place, the lines/tubes your patient has, and what other healthcare members are assisting in their care. Being present, engaged, and invested in your patient’s care is the best way to understand and retain information about their medical conditions and management. 

2 Tips for Learning in Clinical Scenarios 

1. Take Ownership for Your Patients

Be invested and take ownership of the decisions your team makes for your patient. Replace the phrase “The team decided…” with “We decided….” Consider that in a short span of time, you will be in charge and your decision will impact the patient directly. When the team decides to remove the foley catheter, ask yourself, is that a good decision or a bad decision? Why is it a good decision or a bad decision? Why on day one, and why not wait one more day? If you disagree with something or don’t have an opinion, it’s almost always a learning opportunity. 

2. Blend Some of Your Studying Together

Much of the learning inside the hospital will feel separate from the studying you do for the shelf exam. However, some of it can be blended. As you are working your way through a rotation textbook, or Qbank questions you will notice concepts like “How to diagnose pneumonia” or “What is the next best step in management for a patient with heart failure?” You will inevitably get the chance to evaluate a patient with a fever and a cough (maybe it’s pneumonia) or to assess a patient with heart failure.

Take those opportunities! Take ownership and come up with your diagnosis and your plan. Regardless of whether you are right, the patient, the clinical context, and the way your team manages the patient will stick with you! Trust me when I say, pneumonia and heart failure are diagnoses to be intimately familiar with for shelf exams and STEP/COMLEX 2. 

Put your knowledge to the test with this FREE shelf exam practice quiz of the most commonly missed shelf questions from the Rosh Review Shelf Exam Qbanks (one for each specialty)! How many questions can you get?

Further Reading

Going from M2 to M3 is an exciting moment in the life of a student. But there are some things to look out for when you reach this important milestone. Keep these four changes, three pitfalls, and two tips in mind when you start your clinical work, and you’ll not only get the most you can from this time but be ready to crush the shelf exams as well!

If you’d like to further your knowledge and prep for clinical rotations, here are some extra (free!) resources on the Blueprint blog:

1. How to Honor Your Clerkships
2. How to Introduce Yourself to Patients During Rotations
3. How to Introduce Yourself to Physicians During Rotations
4. How to Study For Shelf Exams: A Tutor’s Guide
5. Best Shelf Exam Study Resources: A Comparison & Breakdown
6. Clerkship Pitfalls: What Is Situational Awareness in Healthcare?

Situational awareness is defined as conscious knowledge of the immediate environment and the events that are occurring in it—or, as stated in Endsley’s situational awareness models, “the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future.”

In this post, we’ll explore what situational awareness is, how to use this model while interacting with patients on rotations, and the importance of situational awareness in healthcare.

What Is Situational Awareness?

Situational awareness began as a foundational theory used for making sound decisions in military planning, law enforcement, and aviation. Healthcare practitioners have since adopted it to promote effective leadership, communication, and better patient outcomes. From Endsley’s models, situational awareness can be broken down into three levels: 1) perceiving your environment, 2) comprehending the meaning of the information obtained, and 3) determining events or actions in the future.

A lack of situational awareness when doing a procedure or taking care of a patient can be detrimental to overall patient management. This can result in a serious compromise of patient safety, so having good situational awareness in healthcare settings is of the utmost importance. 

Case Study: Situational Awareness in a Healthcare Setting

Let’s look at an example that demonstrates the importance of situational awareness for healthcare practitioners. Imagine you see a postoperative patient on morning rounds, and instead of her being her usual perky self, she is somewhat lethargic. She had an intermittent dip in blood pressure overnight, but the team assumed it was because she had been asleep and ignored it. Additionally, she was slightly tachycardic, but they thought it was because she hadn’t had her pain medication that morning. Otherwise, everything seemed fine. The patient had no abnormalities in her labs and her progress was good.

And then suddenly, she took a turn for the worse. The team had to play catch up and stabilize her—tt turned out they had ignored subtle clues that there was something wrong. They assumed there were simple explanations for her lethargy, the changes in her blood pressure, and the tachycardia. The team had tunnel vision, and now, the patient was in trouble.

Of course, this crisis could have been avoided if the team members had paid more attention. In situations like these, the entire medical team has a responsibility to notice small details and further investigate them, rather than simply dismissing them. Had one of the practitioners demonstrated more situational awareness, the patient emergency could have been avoided altogether. 

Why Is Situational Awareness Important During Clerkships?

Why is it important to learn about situational awareness as a medical student? Considering you want to succeed in your clerkships, patient safety and progress must be of utmost importance to you. Honing the skills necessary for situational awareness will help you identify subtle cues in your surroundings which may help prevent patient demise if addressed appropriately and in a timely manner. Do not let obstacles prevent you from acquiring situational awareness, because the health of your patients depends on it!

Yet another example comes to mind to enlighten the importance of situational awareness during clerkships and speaking up when a potential error is identified: during your surgical clerkship, going to the operating room and scrubbing cases is considered a part of the rotation. During one of the OR cases, you are asked by the team to drop your gown and gloves onto the sterile field. While attempting to open your gear in a sterile fashion, you manage to contaminate the field entirely. Everyone else in the room is busy getting the patient prepped and ready for the procedure and therefore, they do not notice your mistake.

Your training and understanding of situational awareness should help you immediately identify and act on your error. You should make the whole OR team aware of your mistake so they can rectify the situation in time so as prevent further patient complications and encourage patient safety. A lack of situational and self-awareness, in this case, can lead to patient harm and potentially patient demise.

How to Improve Situational Awareness During Clerkships

As our examples demonstrate, it is crucial for medical practitioners to practice situational awareness at all times. But how does one go about developing this skill? During your clerkships, keep the following areas in mind to make sure your awareness is up to speed in all scenarios.

1. Conscious Self-Awareness

Situational awareness begins with self-awareness. Developing your self-awareness begins with critically evaluating your strengths and weaknesses—do you tend to have tunnel vision? Or maybe you often assume you know why something is happening, without investigating to make sure? Knowing these kinds of things about yourself is key to becoming self-aware, and therefore, situationally aware during patient interactions.

2. Observation

Another critical component of situational awareness is simply being more observant. It is important to watch routine and uncommon events alike to learn how to react to them. This will lead to better patient outcomes, satisfaction, and safety.

3. Foresight

Be able to identify potential threats during patient scenarios by staying knowledgeable about the case at hand. This will help you anticipate any situation and prepare for it.

4. Task Limitation

In addition, make sure to minimize task overload and be mindful of fatigue, which can lead to complacency. If you feel you are not able to keep up with the tasks required of you during a patient scenario, speak up immediately to make sure you do not find yourself in a situation where errors are likely.

Working on these four skills can not only help strengthen your situational awareness but also can encourage more teamwork. Failing to demonstrate them can result in confusion, a lack of communication, and ultimately team errors that can impact patient safety.

Put your knowledge to the test with this FREE shelf exam practice quiz of the most commonly missed shelf questions from the Rosh Review Shelf Exam Qbanks (one for each specialty)! How many questions can you get?

3 Clerkship Pitfalls to Watch Out For

As a medical student developing your situational awareness, there are a few obstacles you may face while developing this skill. These include:

1. Ignorance

 This can be ignorance of the concept of situational awareness altogether, how to practice it, or a lack of knowledge about why it is a necessary skill. Work on developing your understanding of what situational awareness is, and how a lack of it can negatively impact patient care. 

2. Denial

This can be a form of thoughtlessness or a simple refusal to face the possibility that a threat exists. Don’t just ignore the signs that something is wrong, or dismiss them with explanations that may not be completely accurate. Denial can place your patient in danger and prevent them from receiving proper care.

3. Distraction

Misplaced attention to less important details can happen in healthcare settings, and it must be rectified to avoid potential errors. Put anything not related to your patient’s health on the back burner—it can wait.

Further Reading

In conclusion, situational awareness is of utmost importance in healthcare and must be intentionally practiced at all times to ensure patient safety and well-being. Especially for medical students on rotations, it’s important to start learning this skill early to improve patient outcomes for the rest of your career.

If you’re interested in learning more about how to develop your skills on rotations, check out these other Blueprint blog articles!

1. How to Introduce Yourself to Patients During Rotations
2. How to Introduce Yourself to Physicians During Rotations
3. How to Survive and Thrive in Your Core Clerkships

Scrubs is consistently described as the most accurate (and fun) medical show out there. If you’re a fan of the series, then kick back and take this quiz to find out which character you mirror the most during your clinical rotations!

Looking for help studying for shelf exams during your rotations? Meet the combined Step 2 & Shelf Exams Qbank with 5,500 practice questions that most closely match what you’ll see on your USMLE Step 2 and all of your shelf exams. Get started with 7-day FREE access!

Now that you’ve figured out your Scrubs avatar, why not dig a little deeper to figure out how they (you) could make clinical rotations easier? Check out these great posts to ensure your shifts aren’t as stressful as a TV medical drama:

• How I Balanced My Clinical Rotations with Shelf Exam Studying
• How (and Why) to Use a Qbank to Prepare for USMLE Step 2
• How to Study For Shelf Exams: A Tutor’s Guide

Image Credits: NBC and ABC