901 N. Washington Avenue Lansing, Michigan 48906-5137 Telephone: (517) 485-5484 FAX: (517) 485-0801 E-Mail: saem@saem.org

Adrienne Birnbaum, MD			Wallace Carter, MD
Albert Einstein College of Medicine			Weill Medical College
Jacobi and Montefiore Medical Centers			New York Presbyterian Hospitals

Goals of the fourth-year medical student embarking on a rotation in Emergency Medicine (EM) are diverse but may include: the pursuit of experience and knowledge in EM; seeking confirmation about whether EM is the "right" career choice; obtaining an insider's view of a particular program/type of program, under consideration as a choice for residency training and "auditioning" or making contacts with faculty who can act as advocates or authors of letters of recommendation. The following suggestions are designed to facilitate the accomplishment of these goals and maximize the potential for a fulfilling experience. None are hard and fast rules. They have been compiled from the personal experiences of faculty and residents in EM.

Choosing an institution
Students may choose to perform a rotation at their home institution, visit another institution, or both. Potential reasons for choosing an "away" rotation include targeting a program or geographic area that the student has potential interest in as a residency training site.

In general, the performance of multiple EM rotations, especially more than two, at different institutions that simply duplicate experiences is probably best discouraged. The fourth year of medical school provides the student with a unique last opportunity to experience various areas of medicine with education as the primary goal. A student might consider supplementing core rotations at the home or other institution with an additional subspecialty elective in an area such as EMS, Toxicology, or Pediatric EM.

Students are encouraged to collect information on available rotations. Rotations may, for example, differ considerably in the level of responsibility for patient care afforded. The true subinternship experience often allows the student to function, under faculty supervision, at the level of care-giver, while a more observational role is the norm in other institutions. Many programs offer a lecture series specially designed for students as well as conferences provided for EM residents. Experiences unique to certain institutions include a level one trauma experience, EMS experience in ambulance and/or helicopter transport, hyperbaric medicine, toxicology, pediatric EM fellowship program, etc. A good source of information on programs offering student electives in EM can be found by visiting the SAEM web page. The Undergraduate Rotations Directory can be found in the table of contents on the home page. This directory includes a variety of information such as: type of hospital(s); patient volume and variety; EMS opportunities; conference information; requirements of the rotation and unique opportunities afforded by the institution. Details about scheduling and availability are also provided.

While the student may be attracted to an institution because of the presence of a particular feature, such as a helicopter program, hyperbaric medicine, toxicology or pediatric EM, the assumption should not be made that students will automatically be exposed to that particular aspect during the standard student rotation. Specialized interests should be directed to the rotation preceptor in advance to design an individualized rotation that includes the specific request.

Begin planning early
Proper supervision of medical students requires faculty supervision, a resource that is limited. As a result, many institutions have a maximum quota of students that they are willing to accept for each rotation block. Students that are interested in EM residency training should plan to perform the student rotation early in the academic year (by October or latest, November) in order to confirm their interest in EM as a specialty and so that evaluations and letters of recommendation from these rotations will be available in time for residency application. Heavily subscribed student electives may fill their quota of students accepted into the rotation by spring of the academic year preceding the planned elective. To avoid being closed out of such rotations, start investigating options early. A student who has special interest in performing an elective at a particular institution that has filled its quota should speak directly to the preceptor of the rotation to express their specific interest in the program.

Strategy
EM is largely fast-paced and hands-on. Students that show enthusiasm, initiative, and interest during the rotation will undoubtedly have the best experience and make the best impression on evaluators. Knowing one's limitations and asking for help when needed must, of course, temper this strategy. Demeanor is all-important in how the student will be perceived. Over-confidence at the student level will be perceived negatively, as will the sense that a student is working overly hard to make a favorable impression. Focus on learning, providing good care to patients and getting the most that you can from the provided experiences. Whenever possible, follow cases through to completion of the pertinent ED work-up and beyond. Ask to observe interesting cases and or procedures that you are not directly involved in.

Be prepared to think like an EM physician
The fast pace of the ED requires EM physicians to focus rapidly on the chief complaint and to efficiently tease out relevant information from the history and physical exam to generate a differential diagnosis and to make prompt decisions about necessary diagnostic tests, disposition and treatment. Depending on the acuity and nature of the problem, treatment may need to be instituted simultaneously with the performance of the history and physical exam. The EM approach to a sick patient is relatively unique in its focus on ruling out diseases in the differential diagnosis that are potentially life-threatening, i.e. the diagnoses that "one cannot afford to miss", even if such diagnoses are not the most likely possibility. Be prepared to rapidly and efficiently work up patients with undifferentiated complaints with this approach in mind.

Faculty contacts, letters of recommendation, etc
Students interested in a career in EM may feel pressure to make the "proper" contacts with faculty. Some pointers to keep in mind follow. First, a lukewarm letter of recommendation from a renowned leader in EM may make a less favorable impression on residency admission committee members than an enthusiastic evaluation from a less well-known faculty member that has worked closely with you and had an opportunity to get to know you personally. If you have not worked particularly closely with any individual who can write a letter for you, the preceptor of the student rotation will often be able to write a letter based on a composite of comments from individual faculty members that you have worked with. Be sure to choose an appropriate time to discuss your career issues with faculty members. In general, it is more appropriate to set up a meeting with a faculty member than to try to discuss personal issues during a hectic ED shift. Under the proper circumstances, most faculty members, including program directors and department chairs will be enthusiastic about discussing EM with students interested in a career in EM.

Consider volunteering to work one or more evening, overnight or weekend shifts, if not required. EM is a 24 hour per day operation. The "off-hours" experience may be significantly different in volume, patient mix, physician coverage and cadence than that of daytime.

Dress and act professionally. While ED attire is often casual, check out the policy on clothing such as scrubs and jeans before you start, to avoid appearing unprofessional.

Be prepared to treat patients of diverse ethnic backgrounds, socioeconomic status, and variable levels of acuity of illness. Keep in mind that the ED serves as the only access to medical care for some patients and that what constitutes an emergency is often in the eyes of the beholder. Be prepared to encounter patients with various overlays of psychosocial issues as well as both organic and functional impediments to history taking and physical exam. Make an effort to be non-judgmental and persevere to do the best job possible under sometimes difficult circumstances.

Do, by all means, use the rotation as an opportunity to talk to as many residents and faculty as possible about EM and/or about their institution. Keep in mind that residents, and even attendings, may not be in a position to compare programs to one another or to give accurate information about programs other than their own and that word of mouth information may be prone to inaccuracies. Finally, remember that no one program is right for everyone.

Be cognizant of personal safety. The hectic, fast pace of the ED, combined with the large number of procedures performed on ED patients, can be a recipe for disaster if the proper universal precautions are not adhered to. Students rotating through the ED are particularly prone to injuries such as needle-stick or other exposure to body fluids. Glove, gown, mask when appropriate. Never, never, never recap needles. Report any such exposures immediately. Seek help with potentially combative or violent patients.

Reading list
General textbooks of the specialty, such as Rosen, et al. Emergency Medicine: Concepts and Clinical Practice. Mosby, can serve as valuable references but are too voluminous for even the most avid reader to master during a one month rotation in EM. Hamilton, et al. Emergency Medicine: An Approach to Clinical Problem-Solving. W.B. Saunders, is somewhat more manageable for this purpose and is written at the student/resident level. It is organized by chief-complaint, an approach that is particularly useful for students developing an approach to ED patients with undifferentiated problems. Tintinalli, et al. Companion Handbook to Emergency Medicine: A comprehensive Study Guide. ACEP, is an example of a handbook that can provide a portable source of basic information.

A final word...
A little planning and a lot of enthusiasm, initiative and positive attitude will maximize the likelihood of a positive experience on the EM rotation. Make the best of each clinical and didactic experience. Keep in mind that EM is a hands-on specialty, the art of which is often best learned at the bedside. Make an effort to take care of as many sick patients as possible and to discuss the cases with EM faculty. Enjoy the diversity, excitement, and privilege of being involved in saving lives or at least making a difference in the lives of the patients that you come into contact with in the ED.

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