Thank you for taking some of us medical students seriously instead of many others who think we're a bunch of lazy, whiny students and should just suck it up because it has "always been like that" (no, it hasn't). I personally, again, love to work hard, be diligent, and punctual for the sake of professionalism and a proper clerkship education, but why even bother anymore when we have no legitimate roles under an increasingly stressed system? My notes are fake practice (partly due to EMR because now everything is tracked so it's more cumbersome to authenticate new users and allow residents to use/tweak our notes for actual use), my exams are redundant (but often more existent than residents' exams but overlooked), my presentations hardly ever exist, my exposure to procedures is completely resident/attending based and is often nil...you see our point? All those books that talk about how to "do well" on the wards...how can we when at many sites we do not even have a chance to experientially learn and prove ourselves? Hence, my point about how the formal post-rotation student evaluations these days are also often incredibly vague and hardly distinguish one student from another in many respects: "Diligent. Hard-worker. Keep reading.". And hence my point that in the end, BOARDS ARE ALL THAT MATTER in weeding applicants apart INITIALLY; thus, my point about us wanting to just go home and study in a proper manner (resources only at our disposal outside the hospital) than spend 12+ hours standing around. Step 1/2 matter so much more nowadays.
I think it's a little bit of everything compounding the problem. I'm not sure what percentage of M3's/DO/MD clinical sites are associated with it, but I definitely believe the increasingly litigiousness nature of American healthcare/malpractice and the increasing demands of patients (and "prospective patients") lead to even less incentive for medical students to hold a more substantial role on the wards. Why should I be taught how to properly suture--thinks the surgeon--if the surgeon is concerned the suture won't hold properly in the wrong hands, giving him possibly more work to correct later? Why should residents teach when they themselves are burdened by ever more disgruntled patients, increasing debt burden, and no incentive to teach unless they so individually desire? (Also: Patients who basically get free care: "Why should I have to wait and sit through this student's interview? Can I see the doctor instead? I've been waiting a whole 30 minutes...") I've had some amazing residents and preceptors who took it upon themselves to teach/pimp, but oftentimes these experiences are few and far between.
Additionally—and I'm not sure I've heard others elaborate on this—but I also believe the persistently exponentially changing roles of each specialty contribute to the difficulty in teaching and difficulty in providing an accurate picture of a specialty 5-10 years before said medical student actually becomes an attending in that already-changed field. For example—and this stretches on the time spans—but back in the day, family physicians especially in the countryside used to perform appendectomies, c-sections, vasectomies, and more minor office procedures; nowadays, though it still exists, it is hard to find and even more difficult to find that training actually used in daily practice. Heck, some family practice physicians even go so far as to not do any procedures, or see any children, or do any OB/GYN, and stick to adults...ie. "internal medicine". Or, e.g., OBGYNs used to do amniocenteses; now that they're less commonly done, the MFM-trained OBGYNs basically do them. Or, e.g., Interventional Radiology performs some procedures whereas back in the day other specialties would. Or, e.g., increasingly used interventional, non-surgical procedures provide for situations to replace historically surgical treatments. And so on...
I think it is multi-factorial. In no particular order:
1) EMR has made it less convenient for students to do notes. Not impossible, as some sites are set up for it, but definitely not as easy as pen and paper days. It is worthwhile pointing out, though, that medical student notes were never supposed to be used for anything, at least not in the last 15 years. Some residents and attendings would use them, but this was actually against Joint Commission and billing guidelines. Students can contribute PMFSHx, but that is about it, technically speaking.
2) CPOE. Electonic ordering has essentially removed the ability for students to write orders that are then consigned by a resident. It is still possible, but creates sufficiently more work for the resident, that it is not often used.
3) Liability. It seems like our society is becoming increasingly litigious. Fears of getting sued lead physicians to limit procedures that a resident does.
4) Declining reimbursement. As reimbursement goes down, physicians are under increasing pressure to produce. Residents do limit efficiency, but not he extent that med students do. This is due to experience and also related to points 1 and 2 above.
5) Physician scorecards. Whether hospital run or not (think healthgrades.com, etc) physicians want to make sure they remain highly rated due to fear of losing referrals. I am sure there is concern that med student participation will lead to worsening reviews, even if this fear is unfounded.
A few comments on the situation:
1) Med students should do H&Ps, report on rounds, propose plans, document, etc. I still do not think that a note going in the official record is the goal. The goal is the process and I and disheartened to hear that this is not happening at many places.
2) Med students should participate in procedures and surgery. The extent of that participation will depend on the med student, the patient, and the procedure, but helping close is a good start.
3) Attendings who are not willing to take on some liability risk, lower productivity, and risk some poor reviews should get out of academia.
4) Boards are not all that matters. Many places use step 1 scores to weed through applicants on a first pass, but after that letters of recommendation and interview play a much bigger role. Therefore, it is critical to form relationships with faculty in your chosen specialty. You need a good advisor to help with advice regarding away rotations, personal statement, and rank list. You also need good letters from people who know you.
5) While I am sure step 2 matters for some, it doesn't for me or my partners. We pay little, if any, attention to step 2 score.
6) Don't try to predict what any given specialty will be like in 15 years. You can't really tell. In my own field, technology is better but day-to-day practice is very similar to what it was when I was doing sub-I's in 2002.
