How to Think on Your Feet

One of my loyal readers and a current third year medical student asked me a question that I know all of us can relate to: how do you think on your feet? For those of you in high school and college this is relevant when a teacher or professor calls on you for an answer in class or for questions after a presentation, but once in medical school, and particularly the clinical years, being able to think on your feet is a crucial skill! In surgery they call it "pimping" - an attending hasn't spoken to you all case until you get into the bowels and then starts hammering you with questions about why this patient needs this procedure, what vessel you're most likely to hit at this particular location, what's the nerve supply, and so on. On medicine the pimping is a little less shotgun style, but you can still be called on for the answer or your opinion on pretty much anything during rounds. And the pimping never ends. Pimping sounds so dirty, so scary! And while it can be nerve-wracking (the unknown element always is), this is just another part of medical education (that some physician teachers actually do really well), and you can own this!
First and foremost - the people you are around, your team, are what will make you or break you. I don't think I can emphasize it enough but the team is everything in medicine, and the team dynamics are key to feeling safe in a space to think on your feet. It's all too easy as a "lowly" medical student to fall into the shadows and not contribute much to the team - in these cases when you get called on for rounds, this may be the first time the team is even hearing your voice! And you will most certainly be terrified and in no mindset to use that amazing mind of yours. Make sure this is not the case. Make you're best effort to get to know everyone on the team - from the attendings and residents to the nurses and social workers. Even if you're only rotating through (as most of us are), these will be your co-workers for at least a week to maybe a month or two, make it enjoyable and get to know everyone! This way, when you get called on in rounds, it doesn't feel like you're being embarrassed in front of an audience of strangers, but instead surrounded by a group of colleagues who are all trying to help. Granted, everyone does not always want to be friends, but rather you make the effort than not. I think this is part of what makes surgery "pimping" particularly scary for most students - many times you're only working with a surgeon once, but if you'll be there for a week it's still so worth it to try and get to know the residents and scrub nurses who will serve as constants even with different surgeons. Just feeling comfortable around someone who is there when you're on the spot will put you a little more at ease.

If you can succeed in the above you'll eliminate a good chunk of the anxiety that comes with thinking on your feet. The rest comes from, you guessed it, preparation! I think we all know that being prepared is the best way to feel confident, and feeling confident is essential to thinking on your feet, but the problem most of us face is that we don't always have the time to prepare as fully as we'd like. The real skill is figuring out how to prepare efficiently.

Let's say you're on rheumatology. Sure every night you could read chapters from a rheumatology textbook in sequential order, but when your attending asks you about your patient's lupus flare, the fact that you spent all night reading about sarcoidosis isn't really going to matter. So read about your patients! If you're in clinic or inpatient, get a list of the patients on the schedule or that your team is caring for and their diagnosis/chief complaint. Target your studying to what you're actually seeing and you'll be more likely to know what's going on when someone puts you on the spot in rounds. As you're doing your reading think of some questions that could be asked on the subject and come up with answers.

Besides being prepared book-wise, it's also nice to know who's going to be asking the questions (which isn't always possible). But especially on surgery, where surgeons are essentially doing the same procedures daily (and therefore have the same set of questions they're used to asking medical students), get the low-down from upperclassmen or people who have worked with him or her before! Some surgeons are all about numbers - statistics and margin sizes and depth, while others are all about anatomy - even knowing something as general as this can help narrow your focus when you're reviewing. Many people also use Surgical Recall

for common facts that are asked. See this post for some other books useful for the wards!

So you've done your focused reading and feel comfortable around your team, but now the moment comes during rounds that you're called on unexpectedly, what do you do? First, breathe. This isn't really a surprise. Hopefully you were listening. Listening is really important. You need to know and understand what was actually asked. Shy away from stall tactics to buy yourself more time - especially on rounds, things need to be efficient, so no one will appreciate that. Also know, though, that it is ok to have a few seconds of silence. Instead of freaking out in your head, use those few seconds to actually think about what you know. Hopefully you've prepared adequately and you will know the answer, but sometimes we are hit with something really unexpected and that's ok too. In these cases it's completely fine to work your way through the problem out loud and if you hit the "and that's all I know about that" point there's no shame in saying so. Chances are someone else will know the answer and can help out, but if not, make sure to offer to look it up and discuss later. We're all learning, and as scary as being put on the spot is, it's almost always meant to teach us something we need to know.

I hope this post could help some of you with thinking on your feet! It's a skill we can all improve on and will continue needing improvement as we transition to different rotations and places. Remember that although we could all read a little more to feel more prepared, the key to feeling comfortable when put on the spot is feeling safe with your team. Get to know them!