Have we lost perspective, or just evolved with experience?

[SLUser11]

I've been reading a thread off and on in the clinical forums:

When you're a resident, how will you grade your students?


While mostly filled with predictable responses like "I would always let them go home and never pimp them, and they all get honors," I still found it interesting. There's no doubt that SDN is an inherent sample bias, but is this how most medical students think? If so, does that mean that we felt the same way a few years ago, but have lost touch as we've gotten farther outside of medical school?

Granted, there are always going to be jerk residents, and often they unfairly punish students in a "Now it's my turn" sort of hazing ritual, but this definitely doesn't constitute the majority of residents. Most of us are reasonable people who want students to have a positive and educational experience.

Still, students often perceive our behavior as unfair, low-yield, and abusive, and then accuse us of "losing touch" with the plight of the poor med student since our graduation to the next level.

So my question to you guys: Did we lose touch? Should we be easier on our medical students? Or, are students just blind to their bratty, entitled behavior, and too green to appreciate the things we do for their benefit?

We talk about how steep the learning curve is in residency...I wonder if our level of professionalism and maturity have such a steep curve to them as well. There's no doubt that many of us had similar naive notions as med students, and there's also no doubt that today's students will eventually develop into the residents that they currently despise.

So are we getting better, or are we just getting meaner and more jaded as we gain experience in medicine?

Something to think about.....

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[SocialistMD]

My perpective when I was a med student was that I didn't know what was best for me and I followed the guidance of my residents. I was lucky in that none of them were mean and the work I was asked to do was both reasonable and educational. As a resident, I still believe med students don't know what is best for them and I think what I ask of them is educational and fair. Will they work? Yes, but it will be for their benefit.

 

[SLUser11]

My perpective when I was a med student was that I didn't know what was best for me and I followed the guidance of my residents. I was lucky in that none of them were mean and the work I was asked to do was both reasonable and educational. As a resident, I still believe med students don't know what is best for them and I think what I ask of them is educational and fair. Will they work? Yes, but it will be for their benefit.

Yes, but many people will resent you because you are creating extra work for them, and they do not like extra work. They will often view this work as "low yield" or "scut," despite not having a true understanding of the work's yield or the meaning of scut.

Now, do you think that when you were a medical student, you were just lucky to get good residents, or do you think that the work that you thought was "reasonable and education" was interpreted by other students as low yield scutwork?

 

[SocialistMD]

As I said, as a student I never presumed to know what was scut and what was educational. I found education in almost everything. In those things like going to get dinner, I saw them as good for the team, so I also did that without complaint.

 

[ACSurgeon]

I echo what socialist says about viewing most tasks as educational. However, what I view as 'unfair' or crappy treatment from residents depends on how other residents of that same training level and specialty treat students.

For example, during my sub-I in JULY, an intern told a 3rd year student to work on the weekend at the end of the rotation (with the 3rd year student in July not knowing any better they just did). I think that is uncalled for.

I think a little introspection can go along way. Some of the best residents I've had were ones who still remember what it meant to be a student (great teachers, and friendly).

 

[Guile]

Yes, but many people will resent you because you are creating extra work for them, and they do not like extra work. They will often view this work as "low yield" or "scut," despite not having a true understanding of the work's yield or the meaning of scut.

See I think this is a great example of how out of touch residents can become. Believe or not, medical students have a great ability to determine whether something is educational or beneficial. We don't need quite such a paternalistic stance towards our education. Invested in us, yes that is appreciated, but not paternalistic. I've never finished a rotation or looked back on one later, and thought "Oh, thank you Dr. Resident, for making me run bloodwork to the lab and hang out with you until 8pm at night while you ignored me and didn't let me leave. I learned so much from you!" No, we can tell whether we're learning something or not pretty quickly, even if it creates "extra work" for us (if you're a decent medical student obviously). Yes, I would love to try to write admission orders for you. Even if it's wrong, I don't mind re-writing them for you so you can just sign. You can do something else while I'm working and I'll learn something. Win-win for us both. And I don't even mind doing "scut" like getting dinner etc if I feel like the overall experience is a positive one and my residents are nice. Hell I'll get your drycleaning if you're respectful to me and teach me something.

SLUser, what are your expectations for medical students? How do you treat yours more specifically? I'd be able to tell you if it's out of touch or if you've had entitled, bratty students.

 

[joet516]

I'll second Guile's thoughts as a student.

Here's an examples of a negative experience with a resident and how to avoid it (if you care). I'm currently on surgery. At orientation, the clerkship director made a big deal about the shelf/oral exam, which is a third of our grade. Her words: "You need to do well on the shelf. Spend your downtime during the day studying for the shelf or reading about your cases. We know you have to get here early in the morning, so the residents are supposed to let you go by 5 PM at the latest so you can read at night too." Obviously, none of us in our right minds are going to ask to leave at 5 if you haven't given us some indication that its ok.

So, a couple of my friends stayed until 8 the other night because their resident had a central line to do that kept getting pushed back. She had never indicated they could leave, so they stayed around. When she finally got around to the line, one of them gowned up and the other two stood at the foot of the bed. She didn't say one word while she put the line in. Two of the three students couldn't even see anything. Please don't make us stay late and then do this. We really don't gain anything from standing in a room watching you do something, especially if we can't see. Same for watching you do orders, etc.

If there is something you think we should see, have one student stick with you so we can actually get something from it, and make a point to make sure you take each student once. If you tell us that from the beginning, we're going to think you're awesome because you're willing to teaching us one-on-one, even if you're not talking while you put a line in.

 

[Dirt]

The only thing I ask as a med student is to not keep me there because you have to be there, and to remember that you have a med student following you. I get so pissed when I get the "What are you still doing here, you should have left two hours ago."

Well I have been standing right next to you for the past two hours not asking to leave so I wouldn't be remembered as that punk who always asked to leave.

Two of my biggest med student bitching pet peeves though are far too prevalent.

1. Floorwork is not scut it is medicine. (i.e. talking to social work to get the latest on a patient's placement)

2. Asking you to explain what you just said is not pimping. (i.e. why would you get a CT on this patient?)

 

[filter07]

I try to incorporate students as part of the team, with the understanding that as a team, we all do things that are low yield but help out in patient care. I don't ask students to get my coffee but I will ask someone to go get a final read while I take care of something else, so we can multitask as a team. Or ask to write out the h&p while I take the history verbally. Or ask them to do a focused physical while I look up labs and radiology. Stuff like that. If that is considered abusive then abuse ceases to have real meaning.

As far as starting on the night if the shelf, that is kind of tough cookies. Life in surgery is umpredictable and you need to know how to minimize the impact of stuff like that by studying in advance. We all know residents who had to take the Absite postcall.

 

[Guile]

As far as starting on the night if the shelf, that is kind of tough cookies. Life in surgery is umpredictable and you need to know how to minimize the impact of stuff like that by studying in advance. We all know residents who had to take the Absite postcall.

I really disagree with this. Prime example of "my life is unpredictable and crappy as a surgery resident, so yours will be too." The vast majority of medical students aren't going into surgery. We need to maximize their learning of diagnosis and management of surgical disease. If they choose to go into surgery, they have the rest of their careers to get beat on and have a bad lifestyle. As far as getting reads and taking H&Ps, those are learning opportunities and help you understand how to work in a hospital system. I think those are good experiences. But being on the night before the shelf? Come on. What kind of learning experience is that? This is the kind of machismo we don't need. It's detrimental.

 

[kirurg]

I'm not sure if it is detrimental.

I tend to be very easy on medical students. I only have them do work if I supervise and teach them during the entire process. I don't even send them to get reads alone (I think it is unfair to them and to the radiologist- and I tend not to trust anyone). I always let them sleep after 12 or 1 if I'm just doing mundane things. However, this may not really be what's best for them. It may be more beneficial for them to suffer a little, to see what surgery residency is really like, and even do a few points worse on an exam if it would prevent them from going into surgery and then dropping out/wasting a year or more. Most people I know who have left surgery admit they left because they didn't think it would be so "hard". It's one thing to hear residents complain that they're sleep deprived/overworked, but it's another thing to live it.

I really disagree with this. Prime example of "my life is unpredictable and crappy as a surgery resident, so yours will be too." The vast majority of medical students aren't going into surgery. We need to maximize their learning of diagnosis and management of surgical disease. If they choose to go into surgery, they have the rest of their careers to get beat on and have a bad lifestyle. As far as getting reads and taking H&Ps, those are learning opportunities and help you understand how to work in a hospital system. I think those are good experiences. But being on the night before the shelf? Come on. What kind of learning experience is that? This is the kind of machismo we don't need. It's detrimental.

 

[SLUser11]

See I think this is a great example of how out of touch residents can become. Believe or not, medical students have a great ability to determine whether something is educational or beneficial. We don't need quite such a paternalistic stance towards our education......

SLUser, what are your expectations for medical students? How do you treat yours more specifically? I'd be able to tell you if it's out of touch or if you've had entitled, bratty students.

While you may understand educational values well, not all med students share your abilities. Often, they simply think of all things that are unpleasant as being not educational. Or to state it more gently, they frequently underestimate the educational value of an activity.

I understand where you are coming from, but I think you'll feel differently in a couple years.....what I'm trying to decide is if your change of heart will be because you're more experienced, or because you've lost touch.

I'll second Guile's thoughts as a student.
She had never indicated they could leave, so they stayed around. When she finally got around to the line, one of them gowned up and the other two stood at the foot of the bed. She didn't say one word while she put the line in. Two of the three students couldn't even see anything.

This case is easy, because it obviously has a very low educational value. It is the result of a resident that did not clearly state her expectations. This is why I have such an elaborate student orientation at the beginning of the rotation. Telling them when it's okay to leave prevents them from having to ask to leave and seem lazy.

I really disagree with this. Prime example of "my life is unpredictable and crappy as a surgery resident, so yours will be too." The vast majority of medical students aren't going into surgery........If they choose to go into surgery, they have the rest of their careers to get beat on and have a bad lifestyle.

While I agree somewhat, I think that surgery can be a little sugar-coated when we do this, and then people pick it as a career not knowing how much pain is involved. If a student is not exposed to a little of this unpredictability, they may not know that they don't like the surgical lifestyle until it's too late.


As for how I treat my own medical students, I treat them like adults, and I make my expectations very clear. This is in part for their benefit, and it is in part so that I reserve the right to be unhappy if they don't do what I've asked of them. If you don't tell them exactly what you want, then you can't get mad when they don't do it.....I take the "ignorance is no excuse" approach....I'm a product of Catholic education, so I think I come off as a little bit of a hard-@ss. I make sure that the students have some accountability.

I also treat them like a part of the team, meaning that they go home post call, they get 4 days off a month, they don't go over 80 hours/week, etc. To be honest, I show dedication to the learning process, and I make it clear that their education is very important to me, so I usually get excellent student evals, and I've been nominated for teaching awards, etc.


Anyway, I feel like the medical students responding to this thread are tapping into an endless supply of anecdotal bad resident behavior, but it doesn't represent resident behavior in general. There's no question that some bad behavior is not to be condoned...the worst of which is ignoring the medical student...but I feel like there are a lot of gray areas that haven't been discussed. Here are some examples:

1. Resident making the student follow them around all day.----While this can sometimes be bad, it gives the student insight into the daily lives of a busy intern, who's not just rounding on 3 people, then scrubbing surgeries all day. Patient care is a fluid, dynamic process that occurs throughout the day. Without this, I've experienced students who think their 5am progress note pretty much covers their patient responsibility for the day, when in truth it is such a small part of getting that patient healed and home.

2. Asking "pimp questions" in the OR.---If these are obscure questions or worthless facts, like "who invented the ___" or "where was the first ____ surgery done" then of course it's stupid. However, asking about the anatomy of the case, or the pathophysiology of the disease being treated is an essential part of the learning process. The student needs to learn to prepare for the case, and they need to know why we're doing what we're doing. Fear of pimping is the most effective tool I've found for making students prepare for their cases. If they know that no questions will be asked, they lose vigilance relatively quick. Once again, it's about accountability. Of course, I tell my students what sort of questions I'm going to be asking: anatomy, pathophysiology, and then 80's music trivia.




Anyway, so far pretty interesting discussion.

 

[SocialistMD]

I really disagree with this. Prime example of "my life is unpredictable and crappy as a surgery resident, so yours will be too." The vast majority of medical students aren't going into surgery. We need to maximize their learning of diagnosis and management of surgical disease. If they choose to go into surgery, they have the rest of their careers to get beat on and have a bad lifestyle. As far as getting reads and taking H&Ps, those are learning opportunities and help you understand how to work in a hospital system. I think those are good experiences. But being on the night before the shelf? Come on. What kind of learning experience is that? This is the kind of machismo we don't need. It's detrimental.

First off, residents don't make the call schedule. If you have issues with the days you are asked to take call, talk with the clerkship coordinator who can change things, not the resident who can not.

Second, medical school education isn't just about learning how to do h&p's or how to generate a differential. It is about learning the system and how to be a good team member. I don't think I've ever asked a student to do anything unreasonable.

 

[SLUser11]

I don't think I've ever asked a student to do anything unreasonable.

Sure, but don't you think your actions have at some point been interpreted by the medical students to be unreasonable? This definitely isn't a shot at your program, which is excellent, but from what I remember from my time in your city, those students were particularly prone to entitled behavior.

 

[JackADeli]

...1. Resident making the student follow them around all day.----...it gives the student insight into the daily lives of a busy intern, who's not just rounding on 3 people, then scrubbing surgeries all day. Patient care is a fluid, dynamic process that occurs throughout the day...

I have seen complaints about this. But, then what is the alternative... I remember the bold med-student that once said after morning rounds, "Ok, nothing happening now. I'm going to the library. Page me when something interesting is going on...".

One of the biggest worries about limited work hours for residents is that much of the clinical education can not be nicely packaged and scheduled into a "work shift". The med-students are in theory rotating on services for their "clinical years" of "clinical education" component of medical school. It is not scheduled lecture hall like your first two years.

I made a point during residency to mentally keep track of students that have been following around all day with little bang for the buck. This encouraged me to look for special opportunities. Sometimes that meant I stayed up extra late after 2am to take the student through their first central line, arterial line, chest tube, etc... But, if they aren't with me, I am not paging them. Most of the things med-students enjoy are not on scheduled basis.

 

[beefballs]

I just like effort. I try to explain why I am doing and why. I do send med students to bed at midnight on call but they have to respond to teams or if someone is gonna go to the or that night because it has learning value. I want them to get an idea of what and why we o what we do.

 

[SocialistMD]

Sure, but don't you think your actions have at some point been interpreted by the medical students to be unreasonable?

I'm sure, at some point, they have been. But I refer you to my first post in this thread; I know what is educational and they don't. I don't ask them to do or see things that I don't think are educational, so therefore, if they don't find something in which I involve them educational, they are wrong.

 

[Darksmurf]

2. Asking "pimp questions" in the OR.

I don't mind getting pimped by the residents. I actually think it promotes learning because it points out the things that the surgeon or internist or pediatrician think is important to remember about a particular case.

What I hate, as a med student, is when the residents pimp me in French. There's just not enough time on any one service to learn the material and French at the same time, much less the material in French. But every time I explain this to the residents, they just stare at me like they don't understand a word I've said. Now that's frustrating.

 

[maxheadroom]

Ah, the student line, "Page me if something interesting comes up," used to always tell us that the student didn't want to be paged.

My first few years of training were plagued by middle to poor evaluations. My interpretation of this was that the students didn't like to work. My expectation was that students should spend their time on the service pretending to be a junior resident on the service. When I oriented them, I tried to impress upon them the fact that the expectation was that they would learn by doing -- we would have dedicated teaching sessions based upon things that they asked.

Later in my training, a couple of friends and I decided to try an experiment. We shifted our expectations. We told the students that they were visitors on the service and that they were not there to work, but to observe the function of a surgical team and learn whether or not they had an interest in treating patients with surgical disease. We forbade pre-rounding. They were not allowed to be on the floor until 6 a.m., even on days when the team started earlier. We stopped team rounds at 6:45 regardless of where we were on the list and had a 15 minute teaching session about something related to a patient on the service or one of the cases for the day. Students always went to the OR -- they were not allowed to hang out with the interns and do floor work (we told them they could do that as a 4th year AI). Students were allowed to go to one clinic per week with one of the attendings who was close to retirement -- his clinic was slow, so there was time for the resident to do a fair bit of teaching between patients. Students were required to leave the service by 5 p.m., no exceptions -- if you want to stay late, do it on your AI. We fed basic questions to them before cases, so they would have a bit of warning about what we would ask in front of the attendings. We recommended review articles and book chapters that would give them basic info without getting too in-depth. We did not allow students on weekend rounds. We instituted a no-students-past-midnight rule for the students on call -- if you wanted to do late night trauma work-ups, you could do that on your AI (there were enough pre-midnight that they got the picture).

Our mantra was, "We want you to get a taste of surgery, but if you want the full experience, you have to come back for an AI."

The next year, every one of us was nominated for a teaching award. The winner was part of our team.

The funny thing is that over that year, my expectations changed. I actually wanted to students to see the "fun stuff" in Surgery. I wanted them to learn about what surgeons do, but I didn't really want them to live like surgeons while they were doing it.

Now that I'm an attending I have a much more limited interaction with the students. In the OR I ask very basic, benign questions about what we're treating and the basic anatomy. And like SLUser, I pimp them on 80s music.

 

[Jolie South]

I don't mind working hard, staying late, getting pimped and doing tasks that may seem like scut to other students if it helps get the team's work done faster. However, in return, I expect to be acknowledged and have a little teaching time.

Honestly, I haven't had too many "bad resident" experiences. However, one of the things that I really didn't appreciate on my surgery rotation was getting yelled at while helping to close for "doing it wrong" or holding tools "like that" when I've only done this like one or two times before. I understand that I'm not doing it right but belittling me without telling me how to fix the problem isn't going to get me to do it the right way.

 

[DrNick Riviera]

So this thread got me thinking about the best chief i had, both during my sub-I and third year clerkship. He was one of the best residents i saw when it came to walking the line between understanding what was educational and what was not. Firstly, the way he treated his juniors was impeccable. Granted, when the intern was being ******ed and not getting things done, he got reemed out hardcore. But, the chief absolutely put in all the post-op orders on pts he operated on, he made it a point to get the juniors out early even if it meant that he had to finish some notes or consults himself. Basically, he ran the team like a team and not always a dictatorship.

When it came to how he treated med students, he basically let everyone prove themselves in the first few days of the rotation. If it was clear that you had no interest in surgery (beyond sucking up to get honors), he never went out of his way to give you responsibility and pretty much sent you home whenever. But, if you were interested, involved, and made it clear that you prepared for cases and rounds, then you got more freedom. As a sub-I, he had me carrying the consult pager when the intern was out of town, and i really felt like a valued member of the team. That made having to work long hours and do "scut" things quite tolerable.

The only criticism would be that we never seemed to have structured teaching time like other posters have mentioned. But, i personally learn from watching how things are done, and if i cant figure out the why, then ill ask. There will always be those med students who want things spoon fed to them and if it isn't, then they just assume that they are being forgotten and the residents are poor teachers. I think those students end up going into medicine...

 

[Guile]

While I agree somewhat, I think that surgery can be a little sugar-coated when we do this, and then people pick it as a career not knowing how much pain is involved. If a student is not exposed to a little of this unpredictability, they may not know that they don't like the surgical lifestyle until it's too late.

I agree with you and kirurg here somewhat. It shouldn't be soft but if they are serious about surgery then they'll do a sub-internship and can see firsthand what the experience is like more in-depth. I still think the emphasis should be on learning about surgical disease, not getting hammered for 6-8 weeks so you can see what the experience is "really like."

As for how I treat my own medical students, I treat them like adults, and I make my expectations very clear. This is in part for their benefit, and it is in part so that I reserve the right to be unhappy if they don't do what I've asked of them. If you don't tell them exactly what you want, then you can't get mad when they don't do it.....I take the "ignorance is no excuse" approach....I'm a product of Catholic education, so I think I come off as a little bit of a hard-@ss. I make sure that the students have some accountability.

From what you've described, I think you would be have a great resident (and soon to be fellow) to work with. I always liked getting pimped more than ignored because being ignored is such a waste of time. I hate thinking "why am I here?"

Anyway, I feel like the medical students responding to this thread are tapping into an endless supply of anecdotal bad resident behavior, but it doesn't represent resident behavior in general.

I think you're being kind to your fellow residents. I think the things described here are much more common than you might expect unfortunately. It really sucks to be ignored, follow a resident around all day and into the night, waiting for a procedure or something cool, and then not getting to do anything or not being able to see. And then getting told "oh you should have left hours ago!" Gee, thanks.

 

[filter07]

Medical student whining goes to the allopathic forum.

 

[Arcan57]

Later in my training, a couple of friends and I decided to try an experiment. We shifted our expectations. We told the students that they were visitors on the service and that they were not there to work, but to observe the function of a surgical team and learn whether or not they had an interest in treating patients with surgical disease. We forbade pre-rounding. They were not allowed to be on the floor until 6 a.m., even on days when the team started earlier. We stopped team rounds at 6:45 regardless of where we were on the list and had a 15 minute teaching session about something related to a patient on the service or one of the cases for the day. Students always went to the OR -- they were not allowed to hang out with the interns and do floor work (we told them they could do that as a 4th year AI). Students were allowed to go to one clinic per week with one of the attendings who was close to retirement -- his clinic was slow, so there was time for the resident to do a fair bit of teaching between patients. Students were required to leave the service by 5 p.m., no exceptions -- if you want to stay late, do it on your AI. We fed basic questions to them before cases, so they would have a bit of warning about what we would ask in front of the attendings. We recommended review articles and book chapters that would give them basic info without getting too in-depth. We did not allow students on weekend rounds. We instituted a no-students-past-midnight rule for the students on call -- if you wanted to do late night trauma work-ups, you could do that on your AI (there were enough pre-midnight that they got the picture).

Our mantra was, "We want you to get a taste of surgery, but if you want the full experience, you have to come back for an AI."

The next year, every one of us was nominated for a teaching award. The winner was part of our team.

The funny thing is that over that year, my expectations changed. I actually wanted to students to see the "fun stuff" in Surgery. I wanted them to learn about what surgeons do, but I didn't really want them to live like surgeons while they were doing it.

Now that I'm an attending I have a much more limited interaction with the students. In the OR I ask very basic, benign questions about what we're treating and the basic anatomy. And like SLUser, I pimp them on 80s music.

Did you see a increase in the number of students that did AIs and then did not go into surgery?

 

[maxheadroom]

Over the next couple of years the number of applicants to General Surgery held steady, but the number of applicants to surgical specialties appeared to rise. The number of AIs did not seem to change, but students had to do a 4th year rotation in some sort of surgical discipline. Obviously, this is all anecdotal.

Our belief was that the students who were destined for surgery would get enough exposure to follow through and that students who weren't headed for surgery would get a decent experience with the service. The other positive was that the evaluations of the rotation overall went up.

 

[SLUser11]

I agree with you and kirurg here somewhat. It shouldn't be soft but if they are serious about surgery then they'll do a sub-internship and can see firsthand what the experience is like more in-depth. I still think the emphasis should be on learning about surgical disease, not getting hammered for 6-8 weeks so you can see what the experience is "really like."

Well, there has to be a balance. We can't reserve all the bad stuff about surgery for the Sub-I.

If you want to go into surgery, you have usually decided way before you ever do a sub-I. Applications with LORs and personal statements should be ready by September 1st. Away rotations will have already been arranged, etc. If the earliest a student ever sees the surgical underbelly is July of their 4th year, it will really mess with their best laid plans.

Also, I like to work the students hard regardless of their career plans, as long as it's high-yield work. I think many of these principles will lead to them becoming excellent interns in whatever field they choose, be it surgery, family medicine, psychiatry, etc. You want them to take a front-seat role in their medical education, and work hard so they won't be the "weak intern." And every program has a weak intern.

Also, it makes the students going into non-surgical fields have a better appreciation for how hard we work in surgery....often it leads to better inter-specialty relations and consult behavior down the road.

With Sub-Is, I do have to admit that I make them do more "scutwork." While they will obviously be given more freedom and responsibility in the OR, I make sure that they don't take any experience away from the 3rd years, and they spend more time getting ready to be a surgical intern: learning multitasking, following lots of patients (especially in the ICU), trial and error with order writing, reading surgical journals and doing presentations, research etc.

One of my mentors from SLU (Frank Johnson) set me straight when I was a sub-I, saying "you have 5 years to learn how to operate. Let the other students have their turn. You need to focus on how to treat sick surgical patients."

 

[filter07]

During one of my subinternships, I did clinic 5 days a week and went to the operating room I think twice. The M3s went to the OR daily, of course.

But at least it was educational. For a medical student, clinic is one of the most high yield ways to spend time on surgery, IMO. Especially for GI, onc, vascular.

I agree with the post that said M4 year is too late to know what surgery is like. All you need is one co-intern to quit midway into the year to get a much different perspective on what the medical student surgery experience should be. Add to that just people whose personalities don't fit well at all with surgery... makes everyone else work harder.

To answer SLUser's original question, I think one of the explanatory factors is that we are all surgical residents, but not all medical students on surgery are pre-surgery. So whereas our peers and we have certain motivations, work ethic, and interest in surgery, the M3 group as a whole do not. I remember being an intern, coming to this new hospital and thinking this group of medical students were one of the most self-entitled, irrationally self confident group of losers I've ever met. And that's not because I landed a residency much higher in rank than my med school or anything. (Actually somewhat the opposite) Anyway, the point is that I didn't become out of touch in my first month of residency, or that I evolved in that short time frame either. I think a lot of it has to do with the fact, as alluded by Guile, that most people who work with us would rather do normal baby exams or look at black and white images. I rarely had problems with M4s on surgery, probably because they are actually more interested in surgery to begin with.

 

[45408]

As far as starting on the night if the shelf, that is kind of tough cookies. Life in surgery is umpredictable and you need to know how to minimize the impact of stuff like that by studying in advance. We all know residents who had to take the Absite postcall.

And was that good for learning or bad for learning? I think it's pretty miserable to keep 3 students around to watch you do one central line three hours later.

It may be more beneficial for them to suffer a little, to see what surgery residency is really like, and even do a few points worse on an exam if it would prevent them from going into surgery and then dropping out/wasting a year or more. Most people I know who have left surgery admit they left because they didn't think it would be so "hard". It's one thing to hear residents complain that they're sleep deprived/overworked, but it's another thing to live it.

On the flip side, I intentionally took one of the hardest surgery rotations I could, and I don't think I ever tried to get out of anything, so I proved to myself that I could handle it. I don't think it's the residents' job to make you see if you can do it. If the student wants to tough it out, they can. I'm not going to make them. Their evaluation will fairly reflect the amount of effort they put in.

This case is easy, because it obviously has a very low educational value. It is the result of a resident that did not clearly state her expectations. This is why I have such an elaborate student orientation at the beginning of the rotation. Telling them when it's okay to leave prevents them from having to ask to leave and seem lazy.

Which I only had from one single rotation (an easy one), during which I was told by multiple residents that if I stayed past noon, it was my own fault

It's a good idea though - I didn't think about giving them guidelines about when to leave on their own. I'll probably do that some time.

1. Resident making the student follow them around all day.

is SO boring for the student. My best days as a student was being told "Okay, go see these 3 patients, leave a note, and then see this ER consult." The autonomy was great. As an intern, I typically don't mind most busy work, but watching someone else do busy work is just brutally boring

However, asking about the anatomy of the case, or the pathophysiology of the disease being treated is an essential part of the learning process. The student needs to learn to prepare for the case, and they need to know why we're doing what we're doing. Fear of pimping is the most effective tool I've found for making students prepare for their cases. If they know that no questions will be asked, they lose vigilance relatively quick.

We've got a student who scrubs with the attendings who don't ask. My chief picked up on that one pretty quickly.

 

[maxheadroom]

On the flip side, I intentionally took one of the hardest surgery rotations I could, and I don't think I ever tried to get out of anything, so I proved to myself that I could handle it. I don't think it's the residents' job to make you see if you can do it. If the student wants to tough it out, they can. I'm not going to make them. Their evaluation will fairly reflect the amount of effort they put in.

There's a big difference between a hard rotation for four or six weeks and a five year residency. We tried to explain that to the Sub-interns.

 

[Apollyon]

At risk of more ridicule, when I was a resident, there was a student that was a superstar (and, where I was, that says a lot). We had rotated together on a few off-service rotations. I encountered her again when she was a sub-I on a non-surgical service. The resident had some arcane reason why she was going to not give this student honors (it was like Sean Kenniff on the first "Survivor", the way he voted alphabetically to eliminate people - irrespective of how they performed) - I asked the resident why she was doing that, and she wouldn't budge. I didn't push it, because I didn't have a dog in that fight, but it struck me as odd.

 

[45408]

There's a big difference between a hard rotation for four or six weeks and a five year residency. We tried to explain that to the Sub-interns.

But it's not like they have any other way of finding out. I had 9 months of clinicals before I had to decide my M4 schedule, and in order to make that schedule, I had to be pretty sure of what specialty I was going to pick. I had 8 weeks of surgery to decide if that's what I wanted to do for the rest of my life.

It was a rule-out test for me, not a rule-in. If a student can't handle a month of surgery, they won't be able to handle a residency in it.

 

[MossPoh]

Once again, a lot of it seems like how we are raised. I haven't done the rotation yet, but I honestly expect to be beat to $***. I expect to have to do random crap without knowing why when I'm most exhausted, but that is how I was raised. I always got the response along the lines of, "That's nice you want to use the belt sander, but you don't get to until you know how it should be done by hand" for an entire friggin piece of furniture.

Of course, my school doesn't have residents, so I honestly don't know what to expect either. That being said, I really don't want punches pulled for me. I want to learn a lot, but I also want don't want to choose a career based on some constructed, softened version of how things really work.

 

[ZagDoc]

However, one of the things that I really didn't appreciate on my surgery rotation was getting yelled at (or having the resident step in) while helping to close for "doing it wrong" or holding tools "like that" when I've only done this like one or two times before. I understand that I'm not doing it right but belittling me without telling me how to fix the problem isn't going to get me to do it the right way.

This has been a recurrent problem for me. I've never (yes, never) received proper suturing and tying instruction in the OR (this between my MS3 GS rotation, two surgical sub-i's, and two surgical electives) - anesthesia is always in too much of a hurry to wake up the patient and everyone in the room is too impatient to get the case done. The first time I had to do deep dermals, subcuticular, running-locking, etc, etc the resident would generally watch me stumble around then take the needle from me. No help, no instruction, nada, just step in. So I'd go home, watch videos, practice on chicken breast, and get it "good enough". But I know I've taught myself bad habits in the process. I've directly asked for hands-on pointers multiple times without success. It's just madness to me. I know there's an attitude of "you'll learn to be a surgeon when you enter surgical residency," but we all want a solid basic skill set before we start.

Not complaining, I feel like I can close well enough at this point, but since this is a thread about feedback: If you let the student sew, please invest some energy in paying attention and helping them to learn to sew properly. Like a golf swing, you can only "describe" something so many ways, eventually you need to learn the muscle movements by having someone watch you and critique you.

 

[Ronin2258]

There were things I promised myself I would and would not do to students when I was a resident, based on a lot of the bad experiences I had when I did my surgery rotations.

1. If the hospital was quiet, and the patients were stable, I would send them to bed. A few of my nights on call I was subject to lectures at 2am, with numerous pages of "stand by to stand by." An hour on a topic that you could read about, or a hour's worth of sleep? To me, doing lectures like this was more hazing than educational. Not if I have anything to say about it.

2. Get them involved in the fun stuff. Give them the experience. Let them buzz a couple of times. Get them off the pig's feet and onto real human tissue. I had more hands on experience as a scrub tech than I did on my initial general surgery rotation. I was determined to make sure my students would get in on the fun stuff. Yelling was never tolerated by the attendings, I never did it, and our anesthesia team was patient to let the students close. I talked them through it, and let them take their time.

3. Try to teach them the art of finding smoldering embers before they break out into fires at night. Narcotics renewed before the midnight expiration? Did someone remember to do this for that patient? What patient has the chance of going downhill quickly, why, and is there a way to avoid it? Best way to avoid a crisis is to make sure it doesn't come up to begin with.

4. Take possession of my students, and make them part of the team. It means they are MY responsibility to teach, guide them on things to read, make sure they are ready to make the shelf exam their b*#@!. It would be my responsibility to get the students wanting surgery to the right people for letters. If the day was long and it wasn't the weekend sign out, it would be my responsibility to find out if they could be cut loose. Of course, they rounded, wrote notes, and did H&P's. However, the scut was minimal, partially because their first call was to the OR, partially because like someone said, I don't trust results unless I see them myself.

The M3 pulled call overnight only on the weekends where I trained. During the week, it was out when things settled down or 8pm. They went back to the student quarters (only across the street from the hospital,) and be on pager call for trauma and emergent cases. The only scut I would have them do regularly is take care of food for the team (pick up the vouchers, call in the deliveries, etc.) Since I briefed them on my 6 rules, they were more than willing to do so.

As for any degradation of training, I don't know. They seemed to have a good grasp on things as I questioned them throughout the day on the essential topics.

 

[SLUser11]

This has been a recurrent problem for me. I've never (yes, never) received proper suturing and tying instruction in the OR (this between my MS3 GS rotation, two surgical sub-i's, and two surgical electives)

I agree that this type of resident "instruction" is unacceptable. If they don't tell you what to do, then they have no right to be mad if you can't do it.

I would try to find someone who has more of a desire to teach. Unfortunately, when you teach yourself basic surgical technique, it often ends up being pretty crappy technique, and then you don't have a good foundation for the next level.

I do understand about residents always feeling like there's not enough time to teach. Sometimes you feel rushed, and it's hard to watch a student (or junior resident for that matter) struggle and eat up your time. The same goes for postop orders, etc. However, we have to remember that we have an obligation to teach, and the process is inherently inconvenient. The attendings do the same thing for us.

Also, our OR here costs about $60/minute, and obviously letting the student close takes some time. I always thought it was silly that students weren't allowed to use Biogel gloves because they were $1 more expensive than the Perrys when there were some other areas of much more significant expense.

 

[Guile]

Also, our OR here costs about $60/minute, and obviously letting the student close takes some time. I always thought it was silly that students weren't allowed to use Biogel gloves because they were $1 more expensive than the Perrys when there were some other areas of much more significant expense.

Man, they are cheapskates. We can wear Biogels. Some of the med students double glove them which makes me cringe. I like the blue Esteems more (as an underglove) anyway.

 

[Dr.LeoSpaceman]

Man, they are cheapskates. We can wear Biogels. Some of the med students double glove them which makes me cringe. I like the blue Esteems more (as an underglove) anyway.

What's wrong with med students double gloving? Occasionally they'll have their hands in the field, and considering there's no way to predict when that might be, always double gloving seems like the right thing to do. Additionally, it's a good habit to get into.

And I'm a fan of the blue Esteems as well. Perfect for an underglove.

 

[SouthernSurgeon]

What's wrong with med students double gloving? Occasionally they'll have their hands in the field, and considering there's no way to predict when that might be, always double gloving seems like the right thing to do. Additionally, it's a good habit to get into.

And I'm a fan of the blue Esteems as well. Perfect for an underglove.

I actually think it makes MORE sense for students to double glove. They are nearly always standing at the bottom of the table - in the "line of fire" if you have staff who toss instruments in the general direction of the scrub nurse and they don't really have any fine motor tasks to perform.

 

[Guile]

What's wrong with med students double gloving? Occasionally they'll have their hands in the field, and considering there's no way to predict when that might be, always double gloving seems like the right thing to do. Additionally, it's a good habit to get into.

And I'm a fan of the blue Esteems as well. Perfect for an underglove.

I actually think it makes MORE sense for students to double glove. They are nearly always standing at the bottom of the table - in the "line of fire" if you have staff who toss instruments in the general direction of the scrub nurse and they don't really have any fine motor tasks to perform.

But they shouldn't double-glove Biogels. That was my point. It's wasteful. I don't know anyone (outside of misguided med students) who do it. You just need it as your underglove. You can wear a cheapo on top.

 

[igap]

Ah, the student line, "Page me if something interesting comes up," used to always tell us that the student didn't want to be paged.

My first few years of training were plagued by middle to poor evaluations. My interpretation of this was that the students didn't like to work. My expectation was that students should spend their time on the service pretending to be a junior resident on the service. When I oriented them, I tried to impress upon them the fact that the expectation was that they would learn by doing -- we would have dedicated teaching sessions based upon things that they asked.

Later in my training, a couple of friends and I decided to try an experiment. We shifted our expectations. We told the students that they were visitors on the service and that they were not there to work, but to observe the function of a surgical team and learn whether or not they had an interest in treating patients with surgical disease. We forbade pre-rounding. They were not allowed to be on the floor until 6 a.m., even on days when the team started earlier. We stopped team rounds at 6:45 regardless of where we were on the list and had a 15 minute teaching session about something related to a patient on the service or one of the cases for the day. Students always went to the OR -- they were not allowed to hang out with the interns and do floor work (we told them they could do that as a 4th year AI). Students were allowed to go to one clinic per week with one of the attendings who was close to retirement -- his clinic was slow, so there was time for the resident to do a fair bit of teaching between patients. Students were required to leave the service by 5 p.m., no exceptions -- if you want to stay late, do it on your AI. We fed basic questions to them before cases, so they would have a bit of warning about what we would ask in front of the attendings. We recommended review articles and book chapters that would give them basic info without getting too in-depth. We did not allow students on weekend rounds. We instituted a no-students-past-midnight rule for the students on call -- if you wanted to do late night trauma work-ups, you could do that on your AI (there were enough pre-midnight that they got the picture).

Our mantra was, "We want you to get a taste of surgery, but if you want the full experience, you have to come back for an AI."

The next year, every one of us was nominated for a teaching award. The winner was part of our team.

The funny thing is that over that year, my expectations changed. I actually wanted to students to see the "fun stuff" in Surgery. I wanted them to learn about what surgeons do, but I didn't really want them to live like surgeons while they were doing it.

Now that I'm an attending I have a much more limited interaction with the students. In the OR I ask very basic, benign questions about what we're treating and the basic anatomy. And like SLUser, I pimp them on 80s music.

Interesting. Is the goal of the resident/student interaction for the resident to be popular, get good student evaluations, and win a teaching award? Or is the goal of the interaction for the student to gain insight on the life of a surgery resident/surgeon? Not that the two are mutually exclusive, but reducing the student/resident interaction to getting good evals, and winning the "golden apple" award, and making sure the students just do "fun" stuff, seems to marginalize the notion that a rotation is an opportunity for the students to immerse themselves completely in what a surgery resident goes through. Not everything a surgery resident does is educational, or fun.

I don't see the logic in making a student wait until they are a 4th year "AI" to get the full surgical experience. I worked my butt off on almost all of my rotations in medical school. I got an excellent education that I worked very hard for. I also learned which fields I liked and which ones I did not like.

If someone would have given me a watered-down version of reality and made me go home at 5pm, or midnight, or whenever, I would have been ticked. My education is mine, and I will work as hard for it as I want. I don't need pampering, and I don't want it. I'd venture to say that a lot of students do want/need pampering, so your educational strategy is good for winning awards and getting good student evals. But for the students who will be tomorrow's surgeons, I think the surgery-lite approach is misguided.

 

[cpants]

As students, we expect the same thing from you as you expect from us: some enthusiasm. The residents I rated highly were always the ones that had an I-give-a-**** attitude when it came to dealing with students and teaching. That doesn't mean being easy on us or letting us go home early. It means setting clear expectations, taking the time to explain something which may be a little confusing, leading teaching sessions (can be 5 minute sessions or student run sessions), sticking up for students, showing respect, even saying thank you when appropriate. Most students will work their asses off and be happy to do it if they are getting good teaching and are treated like part of the team.

In reference to the situation above, I even had one chief resident tell an impatient anesthesiologist to cool it and keep a patient under for as long as it takes when I was closing. Believe me, it was highly appreciated.

 

[maxheadroom]

Interesting. Is the goal of the resident/student interaction for the resident to be popular, get good student evaluations, and win a teaching award? Or is the goal of the interaction for the student to gain insight on the life of a surgery resident/surgeon? Not that the two are mutually exclusive, but reducing the student/resident interaction to getting good evals, and winning the "golden apple" award, and making sure the students just do "fun" stuff, seems to marginalize the notion that a rotation is an opportunity for the students to immerse themselves completely in what a surgery resident goes through. Not everything a surgery resident does is educational, or fun.

I don't see the logic in making a student wait until they are a 4th year "AI" to get the full surgical experience. I worked my butt off on almost all of my rotations in medical school. I got an excellent education that I worked very hard for. I also learned which fields I liked and which ones I did not like.

If someone would have given me a watered-down version of reality and made me go home at 5pm, or midnight, or whenever, I would have been ticked. My education is mine, and I will work as hard for it as I want. I don't need pampering, and I don't want it. I'd venture to say that a lot of students do want/need pampering, so your educational strategy is good for winning awards and getting good student evals. But for the students who will be tomorrow's surgeons, I think the surgery-lite approach is misguided.

I agree with you in principle, but in practice I haven't found that model to work. The fact is that consistently poor evals reflect badly upon the Surgery Department. We've managed to improve our standing with the students so they're more likely to learn something useful on our rotation (besides "I hate Surgery"). Look at OB/Gyn as an example -- students usually have a very visceral love or hate response to that service.

I think that giving the students a taste of Surgery and then the opportunity to do a hard-core AI works best for the candy-ass students that I had as a resident. It's harder for me to say now that I'm faculty and have less interaction (at a different institution).

 

[Pir8DeacDoc]

This thread makes me glad I only interact with students interested in my speciality. I make every effort to help them learn and give them chances to "operate" but my mission each day to is take care of my patients, my junior residents, myself, and the staff. The students whims and desires are very far down that list.

As an intern I once had a student tell me he didn't want to see another lap chole, he had seen one the day before and so he didn't think seeing another was "educational". I appreciate that students are paying money, but I have work to do, which unfortunately isn't always educational and I can't come up with fun games for them to play while I'm busy.
Of course our hospital is bad about giving the students an idea that surgery isn't so bad, only to have them match at some high powered-malignant program and drop out or come running back here. Our surgery residents work hard, but they are too nice to the students IMHO.

 

[beaverfetus]

I notice ths bizzare trend in surgery whereby the prevous generation continuously impugns the work-ethic and general hard-coredness of the next. Amazingly, this transition sets in approximately 2-3 years after being in med-school.

"In my day, we walked through the snow uphill both ways!"

it's a turn off to the many hard working young people looking at the field.

 

[Winged Scapula]

I notice ths bizzare trend in surgery whereby the prevous generation continuously impugns the work-ethic and general hard-coredness of the next. Amazingly, this transition sets in approximately 2-3 years after being in med-school.

"In my day, we walked through the snow uphill both ways!"

it's a turn off to the many hard working young people looking at the field.

Its not just in surgery. This is a common observation/experience amongst all disciplines and even outside of medicine.

And while it is true that we cannot evaluate our own behavior very well, I can tell you that there *does* appear to have been a change in behavior over the last decade or so.

This does not mean that ALL students lack a good work ethic, but the sense of entitlement and "I'm not paying to see another lap chole" attitude is much more pervasive now than it ever was when I was a student (and yes, I saw it back then but much more now).

And frankly, yes we did work a hell of a lot more hours than students and residents do these days, so WE are entitled to use the old, "I walked both ways uphill in the snow to get to the hospital" (which reminds me of a terrible snowstorm that shut down all the roads during residency; my Chief walked 3 miles in the snow to get to the hospital and sent the hospital 4 wheel drive to get me. There was no calling in because you couldn't get out of your driveway.)

Like it or not, *some* things were harder in the old days.

 

[cpants]

Its not just in surgery. This is a common observation/experience amongst all disciplines and even outside of medicine.

And while it is true that we cannot evaluate our own behavior very well, I can tell you that there *does* appear to have been a change in behavior over the last decade or so.

This does not mean that ALL students lack a good work ethic, but the sense of entitlement and "I'm not paying to see another lap chole" attitude is much more pervasive now than it ever was when I was a student (and yes, I saw it back then but much more now).

And frankly, yes we did work a hell of a lot more hours than students and residents do these days, so WE are entitled to use the old, "I walked both ways uphill in the snow to get to the hospital" (which reminds me of a terrible snowstorm that shut down all the roads during residency; my Chief walked 3 miles in the snow to get to the hospital and sent the hospital 4 wheel drive to get me. There was no calling in because you couldn't get out of your driveway.)

Like it or not, *some* things were harder in the old days.

Maybe part of it is that we pay a lot more dearly for our education these days, with less promise of compensation. I definitely feel entitled to a quality education in exchange for the hundreds of thousands I am paying. Obviously, the "I'm not paying to see another lap chole" attitude is absurd, but if I'm not getting quality teaching and experience on a rotation, you better believe I'm going to be annoyed.

 

[Winged Scapula]

Maybe part of it is that we pay a lot more dearly for our education these days, with less promise of compensation. I definitely feel entitled to a quality education in exchange for the hundreds of thousands I am paying. Obviously, the "I'm not paying to see another lap chole" attitude is absurd, but if I'm not getting quality teaching and experience on a rotation, you better believe I'm going to be annoyed.

And I think that's fair.

You do deserve good and balanced education, regardless of what you're paying. I don't give someone who's paying $50K a year better teaching than someone whose parents are footing the bill. Everyone needs and deserves attention from residents and faculty, time to be taught and an understanding attitude (I despise those anesthesiologists who grumble and groan when I let students close).

But the groaning and moaning, coupled with "I don't wanna see/do/take call/ etc., I'm going to read/study for the Shelf because I am paying X dollars and doing whatever you're doing is a waste of my time" is very annoying to us as well, and many of your colleagues are experts at this type of behavior. Part of learning is also seeing the drudgery, the daily monotony and not just crackin' chests and sticking sharp stuff in people.

Its a fine line for residents and attendings to know when they are not engaging students in the learning process and it can be difficult to gauge what's useful monotony and what really is a waste of their time (regardless of what they're paying).

 

[dpmd]

I always thought of clerkships as a chance to practice being a doctor. It's great if you are at a facility where pt transport, phlebotomy, case managers, etc did their job in an efficient manner. However, I went to school at a place where if you wanted X done now you could either wheel the patient down yourself or wait until _____ got around to it. When the right thing for the pt is to get it done now I don't see a problem with the student doing it (I did it as a student, but also saw the residents do it when the student wasn't around). The flip side was that because it was so busy that having the student do this "menial" task was so helpful, it meant that having the student sew a lac, or see a consult was helpful (or at least my residents always made me feel like it was). I always felt like I was a needed part of the team (even if it wasn't really true), so when stuff needed to get done I was happy to do that which I knew how, and to learn things I didn't.

I expect students to be like I was, and am sometimes greatly disappointed. However, there are also some great ones, and some who don't complain even though they may not shine. Maybe it is because I tell them they are important members of the team and they will have to do some tasks which are not glamorous or fun but are necessary to help the team and the patient. Or maybe they all hate me and just don't have the guts to complain. Whatever, help me have time and I will use some of that time to teach you-or we can all go home early (which seems to be the more desired thing)

 

[beaverfetus]

Its not just in surgery. This is a common observation/experience amongst all disciplines and even outside of medicine.

And while it is true that we cannot evaluate our own behavior very well, I can tell you that there *does* appear to have been a change in behavior over the last decade or so.

This does not mean that ALL students lack a good work ethic, but the sense of entitlement and "I'm not paying to see another lap chole" attitude is much more pervasive now than it ever was when I was a student (and yes, I saw it back then but much more now).

And frankly, yes we did work a hell of a lot more hours than students and residents do these days, so WE are entitled to use the old, "I walked both ways uphill in the snow to get to the hospital" (which reminds me of a terrible snowstorm that shut down all the roads during residency; my Chief walked 3 miles in the snow to get to the hospital and sent the hospital 4 wheel drive to get me. There was no calling in because you couldn't get out of your driveway.)

Like it or not, *some* things were harder in the old days.

And I'm sure you're mentor thought the same thing about your training. And Harvey Cushing would have scoffed at both of you.

The sentiment has been around for a while.

Homer (Iliad): "For rarely are sons similar to their fathers: most are worse, and few are better "

 

[SLUser11]

And I'm sure you're mentor thought the same thing about your training. And Harvey Cushing would have scoffed at both of you.

The sentiment has been around for a while.

Homer (Iliad): "For rarely are sons similar to their fathers: most are worse, and few are better "

13 month bump. I'm bored and the forum is extremely slow (despite 70+ people viewing it currently). This was a great discussion way back in '11, and I'd be interested to hear any new insight.

If this doesn't work to stir up some med student discussion, I will resort to talking about scrub caps or danskos.....