Is med student (relative) autonomy at the lowest ever?

[MedicineZ0Z]

Thought it's just a DO school thing at first but now seeing that it's quite common in MD schools too. Basically the growing pattern of rotations where you're shadowing and/or standing in the corner in some form.

Based on what attendings say, all ms3s had intern level responsibility in the "old days." And north of the border today in Canada, Ms3s put in orders. You need a quality subI that lets you put in orders and treats you like an actual intern.

The outcome is that you're not learning what you need to until intern year. In reality, those things should have been learnt in ms3 and ms4.

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[Gorne]

Thought it's just a DO school thing at first but now seeing that it's quite common in MD schools too. Basically the growing pattern of rotations where you're shadowing and/or standing in the corner in some form.

Based on what attendings say, all ms3s had intern level responsibility in the "old days." And north of the border today in Canada, Ms3s put in orders. You need a quality subI that lets you put in orders and treats you like an actual intern.

The outcome is that you're not learning what you need to until intern year. In reality, those things should have been learnt in ms3 and ms4.

In my experience. This is embarrassingly the case. Med students do almost nothing on rotations at my home institution, or the 3 other institutions I've done away rotations on. 4th year med students with at least 7-8 years of upper-level education, paying tuition to stare at walls, cut sutures, and hold limbs. It's disgusting.

 

[alprazoslam]

Only psych was like that so far

 

[MedicineZ0Z]

In my experience. This is embarrassingly the case. Med students do almost nothing on rotations at my home institution, or the 3 other institutions I've done away rotations on. 4th year med students with at least 7-8 years of upper-level education, paying tuition to stare at walls, cut sutures, and hold limbs. It's disgusting.

Lol or stand in the corner and half-smile while the dr talks to the patient.
I only mentioned Canada because this isn't some 2018 thing that we have to adapt to. Hospitals would save a ton of money by using med students instead of midlevels (which is sorta what happens up there) for the same workload.

Procedures I think we just need less of than before and hence less volume + resident quotas = students get less. But I have seen seniors doing procedures they never will again whereas a student would benefit from it way more.

 

[MSTPlease]

I don’t think the people having the good experiences come on here to brag about it. Only a few days of outpatient peds and outpatient ob/gyn could be described as shadowing. Everywhere else was very hands on. Sure, the orders required approval but that’s mainly because of the EMR. The vast majority of nurses always thought I was a resident anyway and would never seem to grasp that I couldn’t actually put in an order for them so if they could act on a verbal order alone they would have done it.

The volume of knowledge required to practice medicine is also several orders of magnitude higher now than it was “in the old days.” Think about the number of attendings in practice for whom HIV literally didn’t exist when they started. The WHO cancer diagnoses and thus their management change like every 4 years. The advances in surgical tech. The list goes on.

 

[MedicineZ0Z]

I don’t think the people having the good experiences come on here to brag about it. Only a few days of outpatient peds and outpatient ob/gyn could be described as shadowing. Everywhere else was very hands on. Sure, the orders required approval but that’s mainly because of the EMR. The vast majority of nurses always thought I was a resident anyway and would never seem to grasp that I couldn’t actually put in an order for them so if they could act on a verbal order alone they would have done it.

The volume of knowledge required to practice medicine is also several orders of magnitude higher now than it was “in the old days.” Think about the number of attendings in practice for whom HIV literally didn’t exist when they started. The WHO cancer diagnoses and thus their management change like every 4 years. The advances in surgical tech. The list goes on.

Except when you're a midlevel, right? They can have large amounts of autonomy for 100k/year each but a med student costing -50k/yr cannot. Seem legit.

I would agree with you if it wasn't a race to the bottom. We're basically seeing what the lowest possible qualifications are to practice medicine and simultaneously making med school into internet school.

 

[nimbus]

The volume of knowledge required to practice medicine is also several orders of magnitude higher now than it was “in the old days.” Think about the number of attendings in practice for whom HIV literally didn’t exist when they started.

It existed but we didn’t have an effective treatment for it so our patients were dying horrific deaths from it. 3/4 of my medicine service during internship was AIDS and they all died. The old days certainly weren’t good. There was still a large volume of stuff to know but many of those topics are less relevant now e.g. cryptosporidiosis, pcp, HSV pneumonia, CMV, etc. MDR TB was big then as it is now.

 

[Oso]

When I was a 3rd year student I presented on rounds, called consults, explained stuff to families, did random scut work like obtain OSH records and stuff. Wasn't too much, but it wasn't shadowing either.

3rd years do not know enough to properly put in orders. You may think you know a lot, but you actually kinda don't.

The outcome is that you're not learning what you need to until intern year.

You can't put in orders and stuff until you learn the basics. These past two days, I basically told the students what to say on rounds, and they still ****ed it up. That's totally fine and expected, but shows that they're still learning the basics.

Ideally, you would get sign out with us, review the data/labs, come up with your own plan, then we would discuss the plan, you would present on rounds, then you would help us follow up on labs/imaging, help with consults, check in on patients, do some reading on what's going on, and leave at a reasonable time so you can study for your exam.

You may have to be proactive about it, but, at least for inpatient rotations like IM, peds, neurology, I think most people would let you do these things.

You can't expect to be treated like an intern when you don't know ****. I'm not trying to be mean, that's just the truth.

 

[MedicineZ0Z]

When I was a 3rd year student I presented on rounds, called consults, explained stuff to families, did random scut work like obtain OSH records and stuff. Wasn't too much, but it wasn't shadowing either.

3rd years do not know enough to properly put in orders. You may think you know a lot, but you actually kinda don't.



You can't put in orders and stuff until you learn the basics. These past two days, I basically told the students what to say on rounds, and they still ****ed it up. That's totally fine and expected, but shows that they're still learning the basics.

Ideally, you would get sign out with us, review the data/labs, come up with your own plan, then we would discuss the plan, you would present on rounds, then you would help us follow up on labs/imaging, help with consults, check in on patients, do some reading on what's going on, and leave at a reasonable time so you can study for your exam.

You may have to be proactive about it, but, at least for inpatient rotations like IM, peds, neurology, I think most people would let you do these things.

You can't expect to be treated like an intern when you don't know ****. I'm not trying to be mean, that's just the truth.

Then that's a fault of years 1 & 2, clearly. And I don't think this is just 3rd year. It's just a growing trend for both years 3 & 4 where you spend more and more rotations doing nothing.

 

[Goro]

I wonder if the lawyers have something to do with this

 

[MedicineZ0Z]

I wonder if the lawyers have something to do with this

I think schools in the south (where there's less liability issues) give more autonomy. So yeah that could be it. Same thing with my case for up north.

 

[Oso]

Then that's a fault of years 1 & 2, clearly.

Years 1 and 2 teach you basic foundational stuff + basic clinical medicine like how to interview and examine a patient.

If you think you can show up to third year with the actual knowledge you need, then you're mistaken. That's the whole point of 3rd/4th years (and residency).

Where are you getting your data on these trends? At my school and where I am for residency now, the students are not sitting around doing nothing (though for residency I can only speak to pediatrics).

 

[MedicineZ0Z]

Years 1 and 2 teach you basic foundational stuff + basic clinical medicine like how to interview and examine a patient.

If you think you can show up to third year with the actual knowledge you need, then you're mistaken. That's the whole point of 3rd/4th years (and residency).

Where are you getting your data on these trends? At my school and where I am for residency now, the students are not sitting around doing nothing (though for residency I can only speak to pediatrics).

Yaya and midlevels show up for independent practice after 2 years of fluff and some shadowing. Can't have some sort of double standard when it's the same job description.

No one is showing up to 3rd year with practical knowledge. But you should gain it over the course of a rotation and be able to put in orders to manage bread and butter cases by the end. You learn by doing, not by saying you would do so and so.

 

[mehc012]

When I was a 3rd year student I presented on rounds, called consults, explained stuff to families, did random scut work like obtain OSH records and stuff. Wasn't too much, but it wasn't shadowing either.

3rd years do not know enough to properly put in orders. You may think you know a lot, but you actually kinda don't.



You can't put in orders and stuff until you learn the basics. These past two days, I basically told the students what to say on rounds, and they still ****ed it up. That's totally fine and expected, but shows that they're still learning the basics.

Ideally, you would get sign out with us, review the data/labs, come up with your own plan, then we would discuss the plan, you would present on rounds, then you would help us follow up on labs/imaging, help with consults, check in on patients, do some reading on what's going on, and leave at a reasonable time so you can study for your exam.

You may have to be proactive about it, but, at least for inpatient rotations like IM, peds, neurology, I think most people would let you do these things.

You can't expect to be treated like an intern when you don't know ****. I'm not trying to be mean, that's just the truth.

This sounds like what my IM rotation was like, plus/minus scavenging procedures in the afternoon if that was your thing (it was mine ). It helps if you have your notes written before rounds.
Neurology was...sort of like this, only the attendings duplicated literally everything you did or asked, so it was kind of a PITA because anything you did, you had to watch be re-done in excruciating detail, so the more thorough you were, the more bored you were later during the second showing.

As for the orders part...I know that I do not know the dosing for most things. Usually, that's discussed during rounds and I write it down so I know what's needed and can double check that it's updated in the chart later. At this point, when I'm coming up with a plan, I never include the dosing because it's honestly a major victory if I picked remotely the right drug class, lol. There would be no point in me putting in orders, because I'm wrong often enough that I would hate for my orders to be anywhere in the system until after the team talks about the actual plan...at which point someone can efficiently enter them at bedside during rounds anyway.

Plus, I actually started 3rd year early (that's an option at my school if you want to take Step after clinicals), so I had a good 3mo head start with our EMR before the new interns came in, and since I'd paid attention when things were being entered before, I've been able several times to help them navigate and put in the right orders. It's been just enough exposure to know that I am not ready to be entering orders myself, and I am OK with that. I mean, I'm physically capable and tech-savvy enough to literally enter the orders, but there are a lot more details that go into it that we don't think about as medical students, that make a giant pile of logistics hassle for EVERYone if they're done wrong, and I'm OK seeing it done another 5 bajillion times before I consider starting to do it myself.

(As a side note, there's a backdoor in our EMR that allows students to pend orders for a real doctor to sign later...but if you do so, once you enter it you have ZERO ACCESS to edit it in any way. So unless you're 100% confident in your ability to enter the correct orders with no mistakes, whatsoever, in exactly one try, AND you have a resident who welcomes the opportunity to track down your crappy orders, review them, and fix minor mistakes in them in a process far more tedious than going through all of the drop down menus themselves in a fresh order set...you're setting everyone up for a Very Bad Time if you do this. Which is probably why most students aren't even aware that this is a thing that the system allows us to do.)

 

[Oso]

Yaya and midlevels show up for independent practice after 2 years of fluff and some shadowing. Can't have some sort of double standard when it's the same job description.

No one is showing up to 3rd year with practical knowledge. But you should gain it over the course of a rotation and be able to put in orders to manage bread and butter cases by the end. You learn by doing, not by saying you would do so and so.

Come on dude don't make this yet ANOTHER thread about midlevels.

When you are an intern you will realize how it makes no sense for 3rd years to be putting in orders. I know that's a cop out response, but it's true.

 

[MedicineZ0Z]

Come on dude don't make this yet ANOTHER thread about midlevels.

When you are an intern you will realize how it makes no sense for 3rd years to be putting in orders. I know that's a cop out response, but it's true.

Nice response to justify 100k of tuition for ms3-4. I bet the lawyers love your style.

 

[mehc012]

Come on dude don't make this yet ANOTHER thread about midlevels.

When you are an intern you will realize how it makes no sense for 3rd years to be putting in orders. I know that's a cop out response, but it's true.

Hell, if you pay attention during 3rd year, you'd realize this.

Nice response to justify 100k of tuition for ms3-4. I bet the lawyers love your style.

If I put in orders right now, instead of thinking through the patient and trying to figure out "OK, what treatment makes the most sense for this case?", I could easily see myself getting bogged down in "OK, what are the default order sets for a patient being admitted for [chief complaint]? Crap, what was the outpatient metformin dose they were on, again?" and learning more about how to follow formulas and institutional norms than about how to think through cases.

Obviously we will learn the dosings and time-saving algorithms along the way, but I like that we start out just being asked "OK, so what should we do for this patient and why? How are you going to choose a drug class? Which drug within that class? And so on, without being bogged down by How It's Done Here, or What the 10B Nurses Like, or Which Drugs Are On Formulary This Quarter?

 

[deleted103644]

Are medical students even allowed to put in actual orders? This may vary state by state, but on my subinternship, I could only place preliminary orders in the EMR that had to be signed by my intern/resident/attending before they actually were acknowledged.

 

[MedicineZ0Z]

Are medical students even allowed to put in actual orders? This may vary state by state, but on my subinternship, I could only place preliminary orders in the EMR that had to be signed by my intern/resident/attending before they actually were acknowledged.

Med students should not be placing actual orders that are not cosigned.

I have certainly seen scripts that were pre-signed by an attending then written by a student. Also seen orders place on an attending's emr by a student. Yes done both too, many times.

Those prelim orders are a huge part of the learning process.

 

[Oso]

Nice response to justify 100k of tuition for ms3-4. I bet the lawyers love your style.

Ok well now you're just being an ass. Like I mentioned above, the point of m3 is not to shadow, but to learn the basics of clinical medicine and how to come up with assessments and plans. Don't get mad at me for the tuition costs ... like that's not my fault dude? And what is this about lawyers?

Whatever man, there's no talking sense into you. I'm out.

 

[deleted103644]

Med students should not be placing actual orders that are not cosigned.

I have certainly seen scripts that were pre-signed by an attending then written by a student. Also seen orders place on an attending's emr by a student. Yes done both too, many times.

Those prelim orders are a huge part of the learning process.

Eh, disagree.

Knowing what to order and discussing it with your intern? Sure.

The actual act of placing a preliminary order (which in that system actually slowed down my intern/resident)? Not so much.

 

[deleted103644]

Hell, if you pay attention during 3rd year, you'd realize this.

If I put in orders right now, instead of thinking through the patient and trying to figure out "OK, what treatment makes the most sense for this case?", I could easily see myself getting bogged down in "OK, what are the default order sets for a patient being admitted for [chief complaint]? Crap, what was the outpatient metformin dose they were on, again?" and learning more about how to follow formulas and institutional norms than about how to think through cases.

Obviously we will learn the dosings and time-saving algorithms along the way, but I like that we start out just being asked "OK, so what should we do for this patient and why? How are you going to choose a drug class? Which drug within that class? And so on, without being bogged down by How It's Done Here, or What the 10B Nurses Like, or Which Drugs Are On Formulary This Quarter?

Hey Firefly avatar,

See this if you haven’t yet:

 

[Tenk]

It’s weird. When I was a MS3 I wrote notes and put in orders on the floor and in the ED. Just had to have a cosigner. By the time I was an attending this was no longer the case. Can thank your friendly lawyers and bean counters for these great changes.

 

[CherryRedDracul]

I think schools in the south (where there's less liability issues) give more autonomy. So yeah that could be it. Same thing with my case for up north.

Inner-city med schools, too. I went to one.

 

[takeurmeds02]

Except when you're a midlevel, right? They can have large amounts of autonomy for 100k/year each but a med student costing -50k/yr cannot. Seem legit.

I would agree with you if it wasn't a race to the bottom. We're basically seeing what the lowest possible qualifications are to practice medicine and simultaneously making med school into internet school.

We're just not groomed to be employees the same way that midlevels are. We would have to restructure the whole lay of medical education for this to be a thing (which some would argue needs a change anyway but I digress). Delivery of healthcare is changing so fast that it's just not practical for us to be expected to function as employees. It's not just putting in orders but learning each hospitals way of doing things which can take longer than any time we spend at any one place (~8 weeks) - and doing it all safely! What institution is going to want that type of turnaround having to retrain a group of students every couple weeks with such a high level of liability? Most medstudents are barely solid on which abx to use for a particular disease, let alone how to dose it.

I don't like sitting around either but logistically, I get it.

 

[pawprint]

I agree that it is a huge waste of time for 3rd years to put in orders. I'm not sure why anyone is arguing to gain this ability, you should be glad you don't have to do this and can just focus on the medicine aspect. Order input is going to vary depending on the institution you end up at for residency, so why waste time learning how to do it at whatever rotation you are on in med school? heck, it varies from unit to unit how nurses like to read things and how certain labs/images have to be ordered. Until you end up at the institution for residency, there is no educational benefit from putting orders in. If anything, it takes away time from you being able to look things up and read on topics to talk about during rounds. The job of the medical student is to explain why certain things need to be done for a patient, its a refresher for the residents/attending and gives them the tools to find things in the future when they aren't sure what to do (which is basically all of MS3/MS4). By intern year, you should have tools to figure out how to treat somebody even if you have no idea what to do initially. At that point, you can get bogged down with EMR stuff and learn how to put in orders the exact way they need to be put in.

Be thankful you don't have to put in orders. It in no way makes you any more of a healthcare professional.

 

[TTPpentad]

My MS3 experience has been hit-or-miss depending on the rotation. Family Med was a fair amount of autonomy (going to see patients alone, discussing what my dx and plan were with my attending/resident, doing any necessary pelvics/Paps/fetal monitoring, and then educating the patient).

Peds outpatient was pure shadowing with some attendings. Peds inpatient was a totally different ballgame. I was treated and expected to act like a sub-I. Chose up to 4 patients, prerounded, threw in pended orders and had my resident co-sign after a discussion with them, presented on rounds, called consults, and updated and educated families. It was by far the best two weeks of any rotation yet. I was safe to think on my own, make decisions for my patients, and take responsibility for patient care while under the complete supervision of my resident.

My OBGyn rotation has been a mix of stand in the corner and watch the attending and getting to assist with some stuff (exams, deliveries, C-sections).

What annoys me the most is that certain providers will deny learning opportunities (ie student autonomy) because it is inconvenient for them. They’ve been in our shoes. They know how much it sucks to stand and watch and frankly many of them don’t care. If I had all shadowing rotations during 3rd year, how would I really learn to do anything? I could be a premed, or heck, even a high school student, and shadow. They should be teaching us through graduated responsibility and giving us opportunities to learn hands-on.

 

[deleted407021]

Only one of my 4 rotations as an early OMS3 have been very shadowy. And even then I went and saw patients in the hospital on my own if I wanted.

I haven’t been performing like an intern but I’m also not an intern. I have a while til that would make sense. But I have done procedures and been expected to formally present on my patients and formulate assessments and plans most of the time.

 

[Lexdiamondz]

My MS3 experience has been hit-or-miss depending on the rotation. Family Med was a fair amount of autonomy (going to see patients alone, discussing what my dx and plan were with my attending/resident, doing any necessary pelvics/Paps/fetal monitoring, and then educating the patient).

Peds outpatient was pure shadowing with some attendings. Peds inpatient was a totally different ballgame. I was treated and expected to act like a sub-I. Chose up to 4 patients, prerounded, threw in pended orders and had my resident co-sign after a discussion with them, presented on rounds, called consults, and updated and educated families. It was by far the best two weeks of any rotation yet. I was safe to think on my own, make decisions for my patients, and take responsibility for patient care while under the complete supervision of my resident.

My OBGyn rotation has been a mix of stand in the corner and watch the attending and getting to assist with some stuff (exams, deliveries, C-sections).

What annoys me the most is that certain providers will deny learning opportunities (ie student autonomy) because it is inconvenient for them. They’ve been in our shoes. They know how much it sucks to stand and watch and frankly many of them don’t care. If I had all shadowing rotations during 3rd year, how would I really learn to do anything? I could be a premed, or heck, even a high school student, and shadow. They should be teaching us through graduated responsibility and giving us opportunities to learn hands-on.

It sucks, it really does.

With that said, until you've worked a 100 hour workweek with 24 hr calls, you won't truly understand how important efficiency is. Letting med students have too much autonomy can add an hour to my workday on an inpatient rotation and nearly 2 hours in the ED, and in that time I could be seeing more patients, doing procedures, calling consults or otherwise doing work that expedites patient care and gets me home quicker. When you're working most of the hours you're awake, you're not going to want to add hours to your time that you could be spending with your friends, loved ones. Selfish? Yes. But that's reality.

More importantly, the skill level and fund of knowledge of a given med student can vary widely, some MS3s/4s are ready for residency and can be given a good amount of autonomy and some need to be watched with a hawk's eye. I've seen MS3s miss obvious head trauma, haematemesis, sepsis and other pretty alarming diagnoses - things that could literally kill people. Until you've proven to me you're not a fxck-up, I need to keep you on a tight leash for the sake of patient safety.

I think you're right in that graduated responsibility should be the ideal - if you're an MS4 you should be expected to work up and manage patients with a level of autonomy approaching an intern, and there are plenty of procedures (speculum exams, colposcopy, laceration repairs, I&Ds, IV placement, OR intubations) that are absolutely within the scope of a MS4. With that said, it's important to be aware of the bigger picture and understand that when things are too busy or patients are too sick, teaching will sometimes have to fall by the wayside in favour of efficiency.

 

[bananafish94]

I have not had this experience outside of a few brief outpatient clinics. On all of the inpatient services I've rotated on so far, I interview new patients, write the initial H&P, and present them by myself. I volunteer to do any medical student work like obtaining outside records. Especially for rotations like psychiatry, I talk a lot with family members on the phone and get collateral, etc. Even on my FM outpatient rotation, I felt like I had a considerable amount of autonomy. I saw many patients in a day, wrote notes on all of them, and had to be ready to give quick presentations off the cuff with an A/P.

In talking to older physicians, it seems like there used to be a considerable amount of "scut" that medical students had to do that has now been rendered obsolete by computers. I've talked to people who had to wrangle with literal physical records from some dusty basement, go to the "lab" to get bloodwork results, stuff like that. Obviously, that isn't the case anymore. But I feel like if you can advocate for your own autonomy/competence you can keep yourself quite busy throughout the course of the day, at least for the rotations I've been on so far. Maybe I'll change my tune in the next few months, though.

 

[TTPpentad]

It sucks, it really does.

With that said, until you've worked a 100 hour workweek with 24 hr calls, you won't truly understand how important efficiency is. Letting med students have too much autonomy can add an hour to my workday on an inpatient rotation and nearly 2 hours in the ED, and in that time I could be seeing more patients, doing procedures, calling consults or otherwise doing work that expedites patient care and gets me home quicker. When you're working most of the hours you're awake, you're not going to want to add hours to your time that you could be spending with your friends, loved ones. Selfish? Yes. But that's reality.

More importantly, the skill level and fund of knowledge of a given med student can vary widely, some MS3s/4s are ready for residency and can be given a good amount of autonomy and some need to be watched with a hawk's eye. I've seen MS3s miss obvious head trauma, haematemesis, sepsis and other pretty alarming diagnoses - things that could literally kill people. Until you've proven to me you're not a fxck-up, I need to keep you on a tight leash for the sake of patient safety.

I think you're right in that graduated responsibility should be the ideal - if you're an MS4 you should be expected to work up and manage patients with a level of autonomy approaching an intern, and there are plenty of procedures (speculum exams, colposcopy, laceration repairs, I&Ds, IV placement, OR intubations) that are absolutely within the scope of a MS4. With that said, it's important to be aware of the bigger picture and understand that when things are too busy or patients are too sick, teaching will sometimes have to fall by the wayside in favour of efficiency.

I totally agree with you regarding not being able to teach when it’s super busy and watching MS3’s closely so they don’t kill people. I definitely understand how students get in the way of efficiency and respect that everything in medicine can’t (and shouldn’t) revolve around us. It’s the situations when clinic schedule is light or the ER is slow and they still refuse to let students do anything that bother me. Oh well, 3rd year can only last so long!

 

[Old&InTheWay]

I have not had this experience outside of a few brief outpatient clinics. On all of the inpatient services I've rotated on so far, I interview new patients, write the initial H&P, and present them by myself. I volunteer to do any medical student work like obtaining outside records. Especially for rotations like psychiatry, I talk a lot with family members on the phone and get collateral, etc. Even on my FM outpatient rotation, I felt like I had a considerable amount of autonomy. I saw many patients in a day, wrote notes on all of them, and had to be ready to give quick presentations off the cuff with an A/P.

In talking to older physicians, it seems like there used to be a considerable amount of "scut" that medical students had to do that has now been rendered obsolete by computers. I've talked to people who had to wrangle with literal physical records from some dusty basement, go to the "lab" to get bloodwork results, stuff like that. Obviously, that isn't the case anymore. But I feel like if you can advocate for your own autonomy/competence you can keep yourself quite busy throughout the course of the day, at least for the rotations I've been on so far. Maybe I'll change my tune in the next few months, though.

This was exactly my MS3 experience as well. Had a few rotations where attendings were over-protective of their patients, but for the most part (aside from actually putting in orders) I was able to operate as an intern. The thing that I felt most hampered my autonomy was the fact that at most of the institutions I rotated at, our EMR notes couldn't be used for billing and so someone else had to duplicate the notes I wrote. Some place got around this by having me write a note in Word and copy/pasting into EPIC. I like being able to have my note be THE note because it takes some of the workload off of the rest of the team and frees up time for teaching/learning.

 

[Perrotfish]

Thought it's just a DO school thing at first but now seeing that it's quite common in MD schools too. Basically the growing pattern of rotations where you're shadowing and/or standing in the corner in some form.

Based on what attendings say, all ms3s had intern level responsibility in the "old days." And north of the border today in Canada, Ms3s put in orders. You need a quality subI that lets you put in orders and treats you like an actual intern.

The outcome is that you're not learning what you need to until intern year. In reality, those things should have been learnt in ms3 and ms4.

So there are 2 issues, notes and orders

Notes became an issue recently, when CMS in its infinite wisdom decided that medical student notes could not be billed for, even if they were cosigned by the attending. That meant that, to get paid for the patient, the resident/attending needed to write an entirely separate note from the medical student, which is why medical student notes stopped getting read. This was a catastrophe for medical education, and after some lobbying CMS finally reversed itself in February of this year. So hopefully this should start trickling down to medical school policies within the next 2-3 years, and students can go back to write the definitive H&Ps/daily progress notes for their patients, rather than a separate one that no one reads.

Orders became an issue with the advent of electronic health records. Students have never, legally, been able to order anything. They're not licensed. However, in the days of paper orders, they could still effectively write out the entire order, and the residents would just scribble their signatures on the pile of orders the student wrote (often after the order was implemented, which was technically illegal but no one seemed to mind). With EMRs, there is no hiding who wrote the order, so the licensed physicians just need to put in the orders themselves. If this is ever going to improve we would need to lobby states to create true training licenses for students. That would be a great idea, but to the best of my knowledge no one is working on it right now.

 

[bananafish94]

This was exactly my MS3 experience as well. Had a few rotations where attendings were over-protective of their patients, but for the most part (aside from actually putting in orders) I was able to operate as an intern. The thing that I felt most hampered my autonomy was the fact that at most of the institutions I rotated at, our EMR notes couldn't be used for billing and so someone else had to duplicate the notes I wrote. Some place got around this by having me write a note in Word and copy/pasting into EPIC. I like being able to have my note be THE note because it takes some of the workload off of the rest of the team and frees up time for teaching/learning.

I believe the law actually does allow medical student notes to be billable now (as of last year). I have yet to experience an attending or resident take us up on that though.

 

[Old&InTheWay]

I believe the law actually does allow medical student notes to be billable now (as of last year). I have yet to experience an attending or resident take us up on that though.

It's now in the hands of the billing department at each individual hospital. Many where I am have balked at implementing this for legal reasons.

 

[el_duderino]

It's hit and miss. On my IM rotation in MS3, we had our own patients separate from the interns. Only 2-3 at a time, and our work was supervised by the senior resident, but we'd see them and present them at table or bedside rounds. Same with peds. In the ICU in MS4, it was more or less the same, and we'd sit at the COW putting in orders as other team members presented. But for the most part you're pretty useless and a genuine drag on everyone else. As an intern, I'm relieved when there are no med students around because it means less work for me.

 

[Redpancreas]

It's hit and miss. On my IM rotation in MS3, we had our own patients separate from the interns. Only 2-3 at a time, and our work was supervised by the senior resident, but we'd see them and present them at table or bedside rounds. Same with peds. In the ICU in MS4, it was more or less the same, and we'd sit at the COW putting in orders as other team members presented. But for the most part you're pretty useless and a genuine drag on everyone else. As an intern, I'm relieved when there are no med students around because it means less work for me.

This sounds terrible but as an intern I’m also relieved when the students get sent home. I go to a school where the medical students are more competitive and they’re given far more privilege than my home institution. A lot of them are great, but some have a level of arrogance (I’m better than you mentality) which manifests as them challenging the team’s decisions. Whenever one is on service, it creates more work for me in that I feel the obligation to teach when I really don’t even have time to manage my own problems and when they carry a patient, many act defensive and don’t want to accept help yet they’re not the one’s responsible for what happens when stuff goes wrong.

 

[deleted645092]

So where I rotate we seem to have it pretty good in regards to seeing patients solo in most of our rotations; For my first 3 I would see the patient independently, come up with a plan, discuss the case with the attending, etc, in both our patient and inpatient settings as well as subspecialty consults. This is different on my current peds rotation where I mostly shadow and do occasional exams, but whatever.

Where my concern lies is in the hard skills. On only one rotation have I gotten to perform any sort of procedure; family medicine, where I got to do joint injections, mole removals, sutures, all the basic stuff. But once I got into the hospital any procedural work was gone; by the time 4th year comes around I'll have never done even the most of basic procedures or exams that might be expected of me; placing IVs, replacing wound dressings, and such.

It seems like part of it is delegating duties and medicolegal BS; none of the attendings place chest tubes, drain ascites, replace wound dressings, or even give kids shots anymore. I've asked if I could help out with procedures and they always tell me that IR is going to do something later today or that the legal department won't let students do it. Hell I even got told to stop suctioning a patient once after she couldn't swallow her secretions while myself and the attending were the only ones in the room, because "that's not a medical students job, just go tell the nurse to do it".

I'm going to be embarrassed telling attending next year I've never even seen a certain procedure done, but I don't want to sound like a complainer by telling them I never even had the ooportunity...

 

[Perrotfish]

Where my concern lies is in the hard skills. On only one rotation have I gotten to perform any sort of procedure; family medicine, where I got to do joint injections, mole removals, sutures, all the basic stuff. But once I got into the hospital any procedural work was gone; by the time 4th year comes around I'll have never done even the most of basic procedures or exams that might be expected of me; placing IVs, replacing wound dressings, and such.

It seems like part of it is delegating duties and medicolegal BS; none of the attendings place chest tubes, drain ascites, replace wound dressings, or even give kids shots anymore. I've asked if I could help out with procedures and they always tell me that IR is going to do something later today or that the legal department won't let students do it. Hell I even got told to stop suctioning a patient once after she couldn't swallow her secretions while myself and the attending were the only ones in the room, because "that's not a medical students job, just go tell the nurse to do it".

So the issue with procedures is that

1) The first few times someone does a procedure their error rate is very high
and
2) Each kind of procedure is only done by a certain kinds of physicians.

This is a situation where the ethical thing is to wait until you're a resident, and we know that you're actually going to need the procedure that we're teaching. It doesn't make any sense to expose a patient to the risk of your untrained suturing/chest tube/IV/appendectomy if there is still a chance that you will end up a psychiatrist.

I'm going to be embarrassed telling attending next year I've never even seen a certain procedure done, but I don't want to sound like a complainer by telling them I never even had the opportunity..

There's no reason to be embarrassed. Attendings know what medical education is. They will teach you all the procedures you need to know during intern year.

 

[mehc012]

So the issue with procedures is that

1) The first few times someone does a procedure their error rate is very high
and
2) Each kind of procedure is only done by a certain kinds of physicians.

This is a situation where the ethical thing is to wait until you're a resident, and we know that you're actually going to need the procedure that we're teaching. It doesn't make any sense to expose a patient to the risk of your untrained suturing/chest tube/IV/appendectomy if there is still a chance that you will end up a psychiatrist.


There's no reason to be embarrassed. Attendings know what medical education is. They will teach you all the procedures you need to know during intern year.

#2 is kind of a problem in itself. The fact that the IM residents at my hospital are still scrambling for opportunities to do procedures and become certified is, to me, insane. Some never bother, figuring that the subspecialties will always do it...and they're sadly right. People should have at least some base level of procedural knowledge, imo, and we're losing that. There's no need to call in a specialist team for every gorram needle you stick in a patient.

 

[Perrotfish]

#2 is kind of a problem in itself. The fact that the IM residents at my hospital are still scrambling for opportunities to do procedures and become certified is, to me, insane. Some never bother, figuring that the subspecialties will always do it...and they're sadly right. People should have at least some base level of procedural knowledge, imo, and we're losing that. There's no need to call in a specialist team for every gorram needle you stick in a patient.

I agree if its something that you might need to do in practice. For example no Pediatrician in residency needs to place an IV, the nurse is always better. In a newborn nursery its a valuable skill because the expert you called in residency doesn't exist. Community IM has the same problem: its easy to become reliant on a subspecialty that might not exist when you actually get a job.

On the other hand if you don't do it, at all, then you shouldn't put patient's at risk by learning to do it. For example no Psychiatrist, or future psychiatrist, should be placing central lines.

 

[mehc012]

I agree if its something that you might need to do in practice. For example no Pediatrician in residency needs to place an IV, the nurse is always better. In a newborn nursery its a valuable skill because the expert you called in residency doesn't exist. Community IM has the same problem: its easy to become reliant on a subspecialty that might not exist when you actually get a job.

On the other hand if you don't do it, at all, then you shouldn't put patient's at risk by learning to do it. For example no Psychiatrist, or future psychiatrist, should be placing central lines.

Ehh, I'm of the opinion that anyone with an MD should have some baseline level of knowledge, and to me that includes basic procedures. Just as everyone with an MD learns the anatomy/physiology of the entire body and does all of the basic core rotations...it's a part of the package, and it should be. The US can get too specialized sometimes. Heck, even our 'general' surgeons, as an example, are less useful on the global health front than you'd think, because their focus has gotten whittled down so far that they're missing a lot of what used to be (and elsewhere still is) considered part of base knowledge of surgery.

Maybe our med students are losing autonomy because our residents are losing theirs, first, in a different and subtler way...with the set of skills and medical issues that are considered a part of their scope getting smaller each year.

 

[ciestar]

So where I rotate we seem to have it pretty good in regards to seeing patients solo in most of our rotations; For my first 3 I would see the patient independently, come up with a plan, discuss the case with the attending, etc, in both our patient and inpatient settings as well as subspecialty consults. This is different on my current peds rotation where I mostly shadow and do occasional exams, but whatever.

Where my concern lies is in the hard skills. On only one rotation have I gotten to perform any sort of procedure; family medicine, where I got to do joint injections, mole removals, sutures, all the basic stuff. But once I got into the hospital any procedural work was gone; by the time 4th year comes around I'll have never done even the most of basic procedures or exams that might be expected of me; placing IVs, replacing wound dressings, and such.

It seems like part of it is delegating duties and medicolegal BS; none of the attendings place chest tubes, drain ascites, replace wound dressings, or even give kids shots anymore. I've asked if I could help out with procedures and they always tell me that IR is going to do something later today or that the legal department won't let students do it. Hell I even got told to stop suctioning a patient once after she couldn't swallow her secretions while myself and the attending were the only ones in the room, because "that's not a medical students job, just go tell the nurse to do it".

I'm going to be embarrassed telling attending next year I've never even seen a certain procedure done, but I don't want to sound like a complainer by telling them I never even had the ooportunity...

More than I’ve done lol
Ive removed sutures a few times and I’ve done an ABG.

Overall, I haven’t had a ton of the shadowing stuff. I carry my three patients for IM and I do know them better than anyone on the team.

What gets me is that my school, and Im sure others do it too, has a call requirement for med students. I get the point, but if you’re on a slower IM service, you do a whole lot of nothing after rounds unless your residents have errand-like things for you to do. If there were things to keep me busy, sure why not? But so far, not much. The service I am on tells students not to take call or do weekends. However, if the school catches wind of this (id be stunned if they haven’t.. people cant keep their mouth’s shut), trouble could be coming for those who don’t do what the school says. But at the same time.. am i supposed to directly defy my senior resident and attending?

My other favorite... my school has these requirements for observed h&p’s by students. It is a major struggle to get it completed because when does an attending or upper level have time to stand in the room and watch you ask a patient if they have any allergies?

TL;DR rant.

 

[mehc012]

More than I’ve done lol
Ive removed sutures a few times and I’ve done an ABG.

Overall, I haven’t had a ton of the shadowing stuff. I carry my three patients for IM and I do know them better than anyone on the team.

What gets me is that my school, and Im sure others do it too, has a call requirement for med students. I get the point, but if you’re on a slower IM service, you do a whole lot of nothing after rounds unless your residents have errand-like things for you to do. If there were things to keep me busy, sure why not? But so far, not much. The service I am on tells students not to take call or do weekends. However, if the school catches wind of this (id be stunned if they haven’t.. people cant keep their mouth’s shut), trouble could be coming for those who don’t do what the school says. But at the same time.. am i supposed to directly defy my senior resident and attending?

My other favorite... my school has these requirements for observed h&p’s by students. It is a major struggle to get it completed because when does an attending or upper level have time to stand in the room and watch you ask a patient if they have any allergies?

TL;DR rant.

Same, bunch of respiratory virus swabs, one ABG, some sutures, cerumen disimpaction, rectal, few injections, and I got to drain a giant abscess while shadowing in the ED in my free time. Observed a fair number - thora, para, several joint aspirations/injections on Rheum- but honestly far less than when I was a scribe (tons of central lines, ABGs, chest tubes, intubations, etc. to watch back then).

As for the bolded, you do those on those overnight calls you're so upset about...seriously, it's the most efficient time to get those done. You sit with the on-call resident, wait for the page from the ED, and go down with them on the team's actual first contact with a patient. Your resident opens the computer and charts while you run through the H&P. They ask the questions they have left over, and you both go upstairs.

That way, instead of dragging your poor resident into the patient's room to re-do a thorough H&P that the patient has already sat through 3x (ED, on call when admitted, and on the floor) and that the resident either did themselves or already read about...you get to waste less of their time, let them get their charting done sooner on their call night, and you get to actually do an H&P on a fresh patient and present someone that the whole team hasn't already read about. The resident doesn't have to sit through a duplicate H&P, they just sit there for a less efficient one than they would've done on their own (but with more efficient charting). Win/win/win.

 

[studentdocftw]

Go to a US MD state school...while autonomy isn't comparable to the old days, I've still done a fair amount in my first two rotations..on IM I placed IVs, did venipunctures, ABG, and intubated two patients...followed 4 patients each day, presenting at morning and afternoon rounds every day..so far, one week into OB, I've delivered 2 babies, 2nd assisted on 3 C Sections and got to suction on a Lap due to a ruptured ectopic. As a 3rd year 2 rotations in, I'll take it. I still think we aren't on par with the medical students in the past in terms of procedures, but intern requirement have taken over a lot of medical student opportunities.

 

[Eyeronic]

I will speculate that higher patient volume and thus less overall disposable time have contributed to medical students being relegated to the role of observers. If you're an attending on service, you'll have far less time to hear an MS3's fifth oral HPI, exam, and plan when rounding on 20 patients than on 12 patients. Let's face it, the clinics and the inpatient teaching services are increasingly getting filled to the brim these days.

When I was an intern on a very busy service, if I had a lame duck / invisible senior resident my ability to give the medical student enough attention was slim to none.

When I was a senior resident on a very busy service, if I had an incompetent intern my ability to give the medical student enough attention was slim to none.

Lack of time to give attention to the medical student = less able to trust = less autonomy.

TL;DR: It's hard.

 

[ciestar]

On those overnight calls you're so upset about...seriously, it's the most efficient time to get those done. You sit with the on-call resident, wait for the page from the ED, and go down with them on the team's actual first contact with a patient. Your resident opens the computer and charts while you run through the H&P. They ask the questions they have left over, and you both go upstairs.

That way, instead of dragging your poor resident into the patient's room to re-do a thorough H&P that the patient has already sat through 3x (ED, on call when admitted, and on the floor) and that the resident either did themselves or already read about...you get to waste less of their time, let them get their charting done sooner on their call night, and you get to actually do an H&P on a fresh patient and present someone that the whole team hasn't already read about. The resident doesn't have to sit through a duplicate H&P, they just sit there for a less efficient one than they would've done on their own (but with more efficient charting). Win/win/win.

Well, we have no overnight call, but I see what you’re saying. My senior actually had overnight call on Monday and nobody was admitted.

I’ll use your suggestion for that if I get a chance to tomorrow or whenever.

 

[mehc012]

Well, we have no overnight call, but I see what you’re saying. My senior actually had overnight call on Monday and nobody was admitted.

I’ll use your suggestion for that if I get a chance to tomorrow or whenever.

It was optional for us, but I did one night...most productive time I spent in the hospital, to be honest. And I know I got some A+ feedback from the resident I spent that overnight shift with.

 

[ciestar]

It was optional for us, but I did one night...most productive time I spent in the hospital, to be honest. And I know I got some A+ feedback from the resident I spent that overnight shift with.

This is a requirement for OB so I truly hope so!

 

[MedicineZ0Z]

My MS3 experience has been hit-or-miss depending on the rotation. Family Med was a fair amount of autonomy (going to see patients alone, discussing what my dx and plan were with my attending/resident, doing any necessary pelvics/Paps/fetal monitoring, and then educating the patient).

Peds outpatient was pure shadowing with some attendings. Peds inpatient was a totally different ballgame. I was treated and expected to act like a sub-I. Chose up to 4 patients, prerounded, threw in pended orders and had my resident co-sign after a discussion with them, presented on rounds, called consults, and updated and educated families. It was by far the best two weeks of any rotation yet. I was safe to think on my own, make decisions for my patients, and take responsibility for patient care while under the complete supervision of my resident.

My OBGyn rotation has been a mix of stand in the corner and watch the attending and getting to assist with some stuff (exams, deliveries, C-sections).

What annoys me the most is that certain providers will deny learning opportunities (ie student autonomy) because it is inconvenient for them. They’ve been in our shoes. They know how much it sucks to stand and watch and frankly many of them don’t care. If I had all shadowing rotations during 3rd year, how would I really learn to do anything? I could be a premed, or heck, even a high school student, and shadow. They should be teaching us through graduated responsibility and giving us opportunities to learn hands-on.

A lot of what you're describing, I thought was the standard actually. Being very involved and so on.

It sucks, it really does.

With that said, until you've worked a 100 hour workweek with 24 hr calls, you won't truly understand how important efficiency is. Letting med students have too much autonomy can add an hour to my workday on an inpatient rotation and nearly 2 hours in the ED, and in that time I could be seeing more patients, doing procedures, calling consults or otherwise doing work that expedites patient care and gets me home quicker. When you're working most of the hours you're awake, you're not going to want to add hours to your time that you could be spending with your friends, loved ones. Selfish? Yes. But that's reality.

More importantly, the skill level and fund of knowledge of a given med student can vary widely, some MS3s/4s are ready for residency and can be given a good amount of autonomy and some need to be watched with a hawk's eye. I've seen MS3s miss obvious head trauma, haematemesis, sepsis and other pretty alarming diagnoses - things that could literally kill people. Until you've proven to me you're not a fxck-up, I need to keep you on a tight leash for the sake of patient safety.

I think you're right in that graduated responsibility should be the ideal - if you're an MS4 you should be expected to work up and manage patients with a level of autonomy approaching an intern, and there are plenty of procedures (speculum exams, colposcopy, laceration repairs, I&Ds, IV placement, OR intubations) that are absolutely within the scope of a MS4. With that said, it's important to be aware of the bigger picture and understand that when things are too busy or patients are too sick, teaching will sometimes have to fall by the wayside in favour of efficiency.

If students aren't saving you time, you're done it wrong (100% serious).

This was exactly my MS3 experience as well. Had a few rotations where attendings were over-protective of their patients, but for the most part (aside from actually putting in orders) I was able to operate as an intern. The thing that I felt most hampered my autonomy was the fact that at most of the institutions I rotated at, our EMR notes couldn't be used for billing and so someone else had to duplicate the notes I wrote. Some place got around this by having me write a note in Word and copy/pasting into EPIC. I like being able to have my note be THE note because it takes some of the workload off of the rest of the team and frees up time for teaching/learning.

I honestly didnt known until SDN/reddit that med student notes didn't count. All my notes in Ms3 were the actual note.

Ehh, I'm of the opinion that anyone with an MD should have some baseline level of knowledge, and to me that includes basic procedures. Just as everyone with an MD learns the anatomy/physiology of the entire body and does all of the basic core rotations...it's a part of the package, and it should be. The US can get too specialized sometimes. Heck, even our 'general' surgeons, as an example, are less useful on the global health front than you'd think, because their focus has gotten whittled down so far that they're missing a lot of what used to be (and elsewhere still is) considered part of base knowledge of surgery.

Maybe our med students are losing autonomy because our residents are losing theirs, first, in a different and subtler way...with the set of skills and medical issues that are considered a part of their scope getting smaller each year.

Oh boy this post is dead on accurate. Losing autonomy and hands on skills very rapidly across the board. Everyone needs like 2 fellowships to be competent now.

Go to a US MD state school...while autonomy isn't comparable to the old days, I've still done a fair amount in my first two rotations..on IM I placed IVs, did venipunctures, ABG, and intubated two patients...followed 4 patients each day, presenting at morning and afternoon rounds every day..so far, one week into OB, I've delivered 2 babies, 2nd assisted on 3 C Sections and got to suction on a Lap due to a ruptured ectopic. As a 3rd year 2 rotations in, I'll take it. I still think we aren't on par with the medical students in the past in terms of procedures, but intern requirement have taken over a lot of medical student opportunities.

Did all that and placed 6 central lines and 2 art lines. And several tubes on the floor/icu. I'm the exception with that though...