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Anyone ever...
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I was primarily responding to the poster stating that 24 hour call was useless for those going into FM. If the original student in question has a legitimate medical problem that's a totally different situation.
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The argument that the student is an "FM-bound MS3" is the most problematic part, especially during the beginning of third year. As a recent graduate, who was interested in a surgical subspecialty early on, I still took every opportunity to explore other options in third year and at the very least to ensure I was making the proper choice in plastic surgery. (This included coming in on Saturdays during my FM rotation to work the urgent care side of the clinic.) While I ended up going in to plastic surgery, I have numerous classmates who ended up in primary care specialities after initial interest in surgical specialities, and vice versa.
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I can't speak for other locations, but by and large the medical students we get are not lazy, but are smart and hard-working, even those not destined for surgery. If that were the case, I wouldn't have posted about this one outlier that surprised me so much.
Also, without revealing too much, suffice to say that the report back is medical workup negative for this student. So, he'll have to figure out a way to work while tired like the rest of us.
Also, without revealing too much, suffice to say that the report back is medical workup negative for this student. So, he'll have to figure out a way to work while tired like the rest of us.
D
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Did they rule out fibromyalgia?
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How do your evaluations not count? Our evaluations are anonymous and we don't know who wrote them unless someone writes about something that identifies them. Complaining about evals LOL. The most we can do is keep something from going onto our dean's letter.
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Our system changed about half way through my residency... the med school adopted a policy that the students had to follow the hour restrictions of interns, so no more 24 hour call. So now, they would generally do 1 late call a week while on day hours (6A - 10P) and have a full week of night float at some point (6P-6A). Personally thought this system was miserable -- I'd much rather do the occasional 24hr call and get a postcall day as a student.
That being said -- I thought overnight call was important on GS. You definitely saw some pathology you didn't see during the day. There also was a lot less oversight -- attendings not around the hospital and ready to go, senior residents not available, etc. Those were the times I could let our students do quite a bit. In the OR, I could also let the student take their time closing and such, since we weren't rushing to get to the next case.
GS is an important rotation, even for a FM doc. You need to learn to "talk the talk." Just like psych was important for me so I now know what are appropriate consults and what to expect from them. I'd much rather get a consult from a medicine doc saying "the patient has had 24 hours of RLQ pain, with rebound tenderness. I'm concerned about appendicitis, ordering a CT and sending over to you" rather than "The patient has belly pain, can you check it out?" (I know, lame example, but you get my point)
Do the students need to be as exhausted as me all the time? Of course not. It's our responsibility to understand what each student's needs are. I always made sure my students had eaten and were well hydrated, even if it involved them being a little late for a case. If someone who had been clearly working hard all month said they were exhausted and needed a break, I'd have no problem giving them an afternoon to go relax. If they had a legitimate "life event" that needed to be taken care of, of course they could have the day off. (had one student who needed to file some paperwork or she was gonna get deported. I was actually a little shocked she was worried about asking me....) In exchange, my expectation is that they are enthusiastic about being on surgery, regardless of career goals.
There are plenty of students that try to take advantage. A shocking number actually. I accept a vague, non-specific reason for time off once. After that, I need details or documentation that it was legitimate.
_______
On a different note -- we had PA students rotate on our service as well. Yes, there were lazy students and hard working students on both the med and PA sides. The PA students though were routinely more pleasant to be around, more enthusiastic, came to cases better prepared, complained less. Med students usually had a stronger knowledge base, but that was less important to me. Not trying to start a war, but anyone else have this experience? Always wondered why.
That being said -- I thought overnight call was important on GS. You definitely saw some pathology you didn't see during the day. There also was a lot less oversight -- attendings not around the hospital and ready to go, senior residents not available, etc. Those were the times I could let our students do quite a bit. In the OR, I could also let the student take their time closing and such, since we weren't rushing to get to the next case.
GS is an important rotation, even for a FM doc. You need to learn to "talk the talk." Just like psych was important for me so I now know what are appropriate consults and what to expect from them. I'd much rather get a consult from a medicine doc saying "the patient has had 24 hours of RLQ pain, with rebound tenderness. I'm concerned about appendicitis, ordering a CT and sending over to you" rather than "The patient has belly pain, can you check it out?" (I know, lame example, but you get my point)
Do the students need to be as exhausted as me all the time? Of course not. It's our responsibility to understand what each student's needs are. I always made sure my students had eaten and were well hydrated, even if it involved them being a little late for a case. If someone who had been clearly working hard all month said they were exhausted and needed a break, I'd have no problem giving them an afternoon to go relax. If they had a legitimate "life event" that needed to be taken care of, of course they could have the day off. (had one student who needed to file some paperwork or she was gonna get deported. I was actually a little shocked she was worried about asking me....) In exchange, my expectation is that they are enthusiastic about being on surgery, regardless of career goals.
There are plenty of students that try to take advantage. A shocking number actually. I accept a vague, non-specific reason for time off once. After that, I need details or documentation that it was legitimate.
_______
On a different note -- we had PA students rotate on our service as well. Yes, there were lazy students and hard working students on both the med and PA sides. The PA students though were routinely more pleasant to be around, more enthusiastic, came to cases better prepared, complained less. Med students usually had a stronger knowledge base, but that was less important to me. Not trying to start a war, but anyone else have this experience? Always wondered why.
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I totally agree with everything you said on the top part. 24 hour shifts scattered through the month is vastly preferable to a week of night shifts. Less hurried, more hands on because you're not waiting behind 3 interns to do things. Awesome stuff.
It's easy to be pleasant and enthusiastic when you have more time. Med students are coming off of a 2 month stretch where they sat in the library all day for a test that pretty much determines the next step of their life. Then they get thrown from place to place on a monthly basis where different people have different expectations. Once you start learning the ropes and becoming useful, it's time to move on. There is a lot more to learn and master as is the nature of med school, which I know you're familiar with. Med students have much longer hours and have to study for the shelf on top of it. Pa students are expected to learn to be an assistant, not a physician and the expectations are much less.
I remember when I was on vascular surgery, I was in the hospital over 80 hours a week regularly. Get in at 6, rounded with the interns and residents, went to grand rounds, made presentations, stayed in the or all day, saw new consults and at night, I would write down vitals for all the lists and saw surgical patients with the intern. The PA student that was assigned to one of the surgeons only came in for cases. She was not required to prepare for cases (I don't think she even had computer access), no one pimped her, she didn't see any of the inpatients, wasn't at any of the surgical meetings. I remember one time she left at 9pm and I left at 10 but the next day I was scrubbed in a case and she showed up at noon. She asked me what was going on and I told her and she was like "oh I just got here because I stayed late yesterday, the doctor said it was okay". Then she left in the middle of the second case at 6 while I was there until past 9. If you aren't more pleasant and more enthusiastic when you're doing half the hours with no clinical responsibility, I don't know what will help your personality.
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I could see that being terribly frustrating as a med student.
We treated our PA and med students the same-- Hours, call, general expectations.
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I'm a visiting resident a major academic center currently. I was on in-house call and stayed for all the cases I boarded for the AM (done by noonish, home by 1), which would have put my hours at 31. I had an intern from the "home" program with me who is only allowed to work 16 hours (came in 1-2 pm and left after education at 730) - I feel as many of the incoming students and interns are lazy and go home asap. When I was a medical student, I came in before residents and stayed till the last case was scrubbed, took as much call as possible. Now, gunning students ask to go home, tell you they cant work weekends because they our taking time off to go home and visit friends...unbelievable.
At our institution, most residents work as hard as possible, scrub as many cases, and just fudge hours...only have 5 years of training...lots to see and do!
At our institution, most residents work as hard as possible, scrub as many cases, and just fudge hours...only have 5 years of training...lots to see and do!
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Many programs, including my old one, take the hour rules (especially the 16 hr intern rule) VERY seriously. As an intern, you better have had a damn good reason if you stayed passed 16 hrs.
Also- if your program has its hours audited and you're found to have been lying, it's your butt on the line. Be careful with the "fudging." I've known several people put on probation for lying about hours...
Oh how the times have changed.
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Not a smartass question, but how does your program know if you stayed past 16 hrs? And how would you expect them to find out if you were lying on an audit?
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Plus people talk...
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I don't actually think the ACGME would have access to those things.
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Yes, they do. As a technically "voluntary" association, member institutions have to assist with any ACGME investigation and provide any requested information. Now, the ACGME just can't troll through data looking for a violation. However, if a violation or allegation is reported to them, they would have full access to effectively "subpoena" evidence that would support a complaint. Think of the NCAA and athletic investigations, except that the ACGME is arguably more competently run, and has far more power to enforce compliance.
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Interesting. I had sort of viewed them as like the ncaa but instead of more competently run, less well funded and more understaffed and honestly more impotent. It seems most of the violations you hear about are self reported things and I can't think of any examples I've heard of where people were "caught" in this fashion. Certainly could have happened that I just didn't hear about.
My program was good about hours, too good imo, and I never really had to lie to avoid infractions. That being said I also was sometimes lazy about logging hours and would get a few weeks behind and was not interested in going back and finding out exactly when I actually came and went. Certainly there is no way my hours would have withstood any sort of actual audit with access to the EMR. I'd be surprised if most people's coukd.
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Every "damn good reason" is specifically delineated in the ACGME Common Program Requirements. Page 19 VI.G.4.b).(4). There are specific exceptions for unstable patients, academic important things and humanistic attention.
There is a reason why I have copies of the ACGME rules on my desk...
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Exactly. And as was stated, yes, they do check during an audit!
Its like being in middle school... so much gossip :O
Its a good thing you have it on your desk, but don't know how to read it!
VI.G.4.b only applies to PGY2+ residents. There are no exceptions for interns. Also, as it says, the "program director must review each submission of additional service, and track both individual resident and program wide episodes of additional duty." If you have a long list of violations (even with exceptions) and your program is audited, you will still get cited. I "also" like to "use" "quotes" obnoxiously.
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I had a visiting student say he was really tired during clinic and asked if he could take a nap in the call room while we finished. Not post call. Not anything. We let him...and blacklisted him.
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I've fudged a number of times for unique cases or good learning experiences that I will probably never see again (multi-visceral donor and then transplant recipient, etc). Completely and totally worth it.
Just don't go around saying you've been awake for 30 hours and don't do it regularly.
Just don't go around saying you've been awake for 30 hours and don't do it regularly.
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The rules actually allow you to stay longer for those special cases. No rule breaking present...
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Thought I would update this...
Have heard in a roundabout way that this student did end up with an actual diagnosis. However since it is a very specific diagnosis and I don't know that I was supposed to hear about it, I don't want to post it openly here as it is potentially possible to identify the student with the info I've posted here since many people know my residency location. Suffice to say it it is an unusual dx and I'm not sure if I should have been expected to suspect it in this situation or not, with the info I had at the time. He's now set to resume clinical rotations after appropriate treatment and hopefully he'll be successful.
Trusted members that I "know" can PM me for more information and help me decide if I should have suspected the ultimate dx. It isn't a surgical one, I'll say that much.
Have heard in a roundabout way that this student did end up with an actual diagnosis. However since it is a very specific diagnosis and I don't know that I was supposed to hear about it, I don't want to post it openly here as it is potentially possible to identify the student with the info I've posted here since many people know my residency location. Suffice to say it it is an unusual dx and I'm not sure if I should have been expected to suspect it in this situation or not, with the info I had at the time. He's now set to resume clinical rotations after appropriate treatment and hopefully he'll be successful.
Trusted members that I "know" can PM me for more information and help me decide if I should have suspected the ultimate dx. It isn't a surgical one, I'll say that much.
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Thanks for following up. Not sure I would've done anything differently, but it's important to see that we're not always right. To me at least, this was a lesson to be less judgmental.
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severe fatigue and malaise has only one diagnosis in medical students: hungover
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I like how this thread just kinda went full circle. Poor kid, but I think the responses on this thread are expected. And, as noted already, most med students (at least those I know) would be mortified to simply call-in for anything short of bleeding-out; and that would STILL be to make arrangements to come to the hospital (I kid I kid). But we do have sort-of a "come-in regardless, get sent home if warranted" mentality.
Also I'd like to add that its fine not to be interested in one field or another, but there is always something to learn on rotation. And to be honest, despite the better hours and low-pressure environment, I really had a hard time enjoying FM; just learned everything I could, then moved on. So no sympathy for someone 'suffering' through Surgery rotation. Also 3rd year clerkships are not designed to help student's decide what they want to do per se; rather the intent more towards a strong fondation in clinical training; FWIW; 45% of our match last year went to specialties NOT on our 3rd year schedule.
To residents working with med students; advice appreciated:
Fatigue is no joke - but understandably a part of the job. It seems like 24hrs is really not a big deal; 36 hrs also doable with some sleep after. But I know residents often do much more and for longer stretches. As bad as I want to be a part of this profession, I'd say the one thing that worries me is my ability to think clearly and efficiently after so many hours of prolonged wakefulness.
I have but 3 primary experiences to relate to:
1) Combat - well obviously certain scenarios you just stay awake; they even passed out caffiene tabs and/or [something else] at times
2) School - all nighters, next day tests etc, we've all been there, but eventually you get to just crash, often with nothing to do later
3)Rotation - 24-30hr call is nothing for a 3rd year responsibility wise; follow the intern around, maybe scrub an emergent case or two, and generally just doing what you are told.
But concentration starts to go out the window pronto. Mild headaches, neck stiffness, ringing in the ears, repeating thoughts in your mind, short term memory sluggishness....it all starts as a little waves right before pre-rounds, goes away when things start moving around, then starts progressively setting back in between during that 24-30hr period. As med students we present a couple pts, try our best be attentive and engaged through rounds, then typically just go home if there's nothing to do.
What worries me is when the day comes that I'll be that resident taking on ALL the patients, presenting them ALL (or at least knowing them all while the med student tries to present), then writing all those progress notes after call - accurately, and with pertinent details. only to come back and do it all over again, and again.
I know work-load and responsibilities for interns and uppers vary from service to service. But I gather there is a HUGE jump in responsibility and accountability seemingly over night after med school graduation. How in the world are interns and residents dealing with this in the face of fatigue, sleep deprivation, and exhaustion? Is it just practice? Are you just more comfortable functioning at a baseline zombie-mode? Is it really not that big of a deal and I'm wasting time working about it? Is it that I'm just older and feel it way more than those 5-6yrs my younger? Input appreciated if anyone feels obliged.
Also I'd like to add that its fine not to be interested in one field or another, but there is always something to learn on rotation. And to be honest, despite the better hours and low-pressure environment, I really had a hard time enjoying FM; just learned everything I could, then moved on. So no sympathy for someone 'suffering' through Surgery rotation. Also 3rd year clerkships are not designed to help student's decide what they want to do per se; rather the intent more towards a strong fondation in clinical training; FWIW; 45% of our match last year went to specialties NOT on our 3rd year schedule.
To residents working with med students; advice appreciated:
Fatigue is no joke - but understandably a part of the job. It seems like 24hrs is really not a big deal; 36 hrs also doable with some sleep after. But I know residents often do much more and for longer stretches. As bad as I want to be a part of this profession, I'd say the one thing that worries me is my ability to think clearly and efficiently after so many hours of prolonged wakefulness.
I have but 3 primary experiences to relate to:
1) Combat - well obviously certain scenarios you just stay awake; they even passed out caffiene tabs and/or [something else] at times
2) School - all nighters, next day tests etc, we've all been there, but eventually you get to just crash, often with nothing to do later
3)Rotation - 24-30hr call is nothing for a 3rd year responsibility wise; follow the intern around, maybe scrub an emergent case or two, and generally just doing what you are told.
But concentration starts to go out the window pronto. Mild headaches, neck stiffness, ringing in the ears, repeating thoughts in your mind, short term memory sluggishness....it all starts as a little waves right before pre-rounds, goes away when things start moving around, then starts progressively setting back in between during that 24-30hr period. As med students we present a couple pts, try our best be attentive and engaged through rounds, then typically just go home if there's nothing to do.
What worries me is when the day comes that I'll be that resident taking on ALL the patients, presenting them ALL (or at least knowing them all while the med student tries to present), then writing all those progress notes after call - accurately, and with pertinent details. only to come back and do it all over again, and again.
I know work-load and responsibilities for interns and uppers vary from service to service. But I gather there is a HUGE jump in responsibility and accountability seemingly over night after med school graduation. How in the world are interns and residents dealing with this in the face of fatigue, sleep deprivation, and exhaustion? Is it just practice? Are you just more comfortable functioning at a baseline zombie-mode? Is it really not that big of a deal and I'm wasting time working about it? Is it that I'm just older and feel it way more than those 5-6yrs my younger? Input appreciated if anyone feels obliged.
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Honestly, I wouldn't sweat it all that much. Unless you are a dullard with no situational awareness, if you NEED to be sharp at any given time your body and mind will react accordingly. I don't recall ever feeling exhausted or blunted during a trauma or in the OR or with a sick patient. I certainly remember struggling to keep my eyes open in conference or clinic the next day. Obviously my experience of those events isn't purely objective and I'm sure with a fine enough instrument you could show I was performing at less than peak but it's not like I was forgetting to put on gloves or tying off aortas.
Really the times that concerned me the most are when I would actually get sleep as a senior resident, and then the next day have my junior say things like "sorry I had to bother you with that at 2am, but thanks for your help" And not really have any idea what she was talking about.
Really the times that concerned me the most are when I would actually get sleep as a senior resident, and then the next day have my junior say things like "sorry I had to bother you with that at 2am, but thanks for your help" And not really have any idea what she was talking about.
I knew a guy that did this. He was thrown out of school (not my school, elsewhere) when they realized that he had no underlying illness. He also had a pattern of behavior before that though, so it wasn't just one event. Reporting it to the clerkship director is important for at least that reason, as it helps build a file that allows them to establish a pattern of behavior should it or similar incidents occur in the future.
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Thanks for following up. This is just another reminder for me to be humble and kind. I myself can be a bit judgmental, but situations like this remind me not to practice my righteousness for others to see.
Don't beat yourself up about not catching a tough medical diagnosis. Even the medicine guys took awhile to figure it out, and you didn't have the opportunity to perform a focused history and physical or review his studies.
At the end of the day, common things are common. Much more likely to have a bit of slacking than a rare disease. I would have done the exact same thing. One thing you may consider is asking him (earnestly and without revealing that you may know the diagnosis) how he's doing if you ever run into him, e.g. "did you ever figure that thing out? Was pretty weird. I leave that stuff to the medicine guys." If he wants to share then he can. If he wants to tell you to go f*ck off, he can do that too.
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Maybe you should have paid more attention in your family medicine rotation in med school?
Anyway, that sucks. My response would have been the same as your's honestly but if the dude actually turned out to have been sick I'd have kinda felt like a jerk. Or more specifically had a brief period of insight into the fact that I was a jerk.
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Again, the ultimate diagnosis was something pretty rare and not something that showed up with basic physical exam/labs/imaging. I don't think snide innuendo about my clinical skills is appropriate. Additionally, I don't think I behaved like a jerk. If you look back at my posting from the time of the situation, I had appropriate discussions with the student, I wasn't mean to him, and when the situation got to the point that it would affect his grade (given he stopped showing up for work) it was referred to the clerkship director. The student appropriately took a LOA for this. I've come to the conclusion that I feel bad for the student but that the situation was handled appropriately given the information we had at the time.
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What's the reason for being rude here?
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As a fourth year med student, the part about the shelf exams is both true and somewhat reassuring. At my school, honors is based on primarily our shelf exam performance and i've struggled with dynamic since the beginning of third year. I've earned excellent comments on my evaluations and excellent clinical evaluations; however, I know many of my colleagues that would routinely try to leave as early as possible or hide in the library and yet they would earn the course honors because they spent more memorizing shelf minutiae (and still earned the baseline clinical evals to ensure honors). Compare that to students like myself whom stayed behind on surgery to hold micro-retractors on the last thyroidectomy of the day.. guess what, i got a high pass in surgery while my friend got honors for acing the shelf. It's hard to not feel bitter about such a system as a student and not think that your friends getting honors are doing something right... 🙁
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At my school, the system is biased towards evaluations. But this doesn't work well either since you have a bunch of attendings and residents who either don't know or don't care how the eval grading system works, so a lot of them end up as "passing" evals regardless if they didn't leave a single comment or said you "went above and beyond." And if you don't honor the evals, you can get 99 on the shelf and practical, but still only high pass.
I don't know if there's a perfect system. Everyone would be happy only if they all got honors, and if that was the case you might as well make 3rd year pass/fail.
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At least on a 10 point scale you can have variability. Ours is 1-4, lol. And you have to get 3.5 in 3/5 categories, so basically half of your evals have to be perfect. And if evaluators go by the text description for each one, it would be impossible for students; one clerkship director told me, "Based on the descriptions, I think someone getting 3s is an excellent student." But that doesn't help me, Dr. Soandso!!
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I'll reply to you and winged scapula in one since the general tone was the same.
1. Was I being rude? This is one of those instances where I lack the "brief insight into the fact that I'm a jerk". The OP clearly thought the dude was being lazy (has he ever had a real job?). I indicated I would have thought the exact same thing. But would have felt like a jerk the way things played out. Sometimes that happens. It happened to you.
2. The "maybe you should have paid more attention in your family medicine rotation" was a jab at the whole idea that this kid can't cut it in surgery thing. I put zero effort into family medicine. It's kinda amusing how you didn't pick up on a medical illness while knocking at him for being a flea type guy and not tough enough for surgery. He could maybe knock you for the exact opposite. It's called irony.
In conclusion:
You handled it well. I would have assumed the kid was weak as well and that would make me feel like a jerk if I found out he was ill. You don't feel like a jerk...that's fantastic.
Irony is funny.
I'm probably a jerk.
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The program director from my med school told me "I don't care about (clinical clerkship) grades, because they are too variable and I can't compare applicants with them." I have no idea if this is the norm, but the rationale makes sense to me. If I were a PD I would probably care more about the MSPE than clerkship grades.
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I try to go out of my way and write a nice eval for a med/PA student when dropped in my mailbox. People who do the bare minimum and just show up without being egregiously bad will pass. Those that go above and beyond I think deserve mentioning. The failure in the system is how hard it is to actually fail a terrible med/PA student. It's a whole separate 10-page form about how and why and what we can do to help and be able to show up for an appeal if the med student goes that route. Makes it more conducive to just passing someone along.
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So did this student "just not come in"--ie, no-showed without notice--or did he call in before his shift and say that he couldn't come in because he was tired/sick? You ask if he's never had a real job before--at a "real job," you're given sick/personal time, and the appropriate thing to do is to call in before your shift and notify your boss that you can't come in. At a "real job," you're not paying $50k a year to be there. At a real job, I wouldn't expect my colleague/boss to go tattle to my other boss about calling in ahead of time to notify that I felt too unable to come in. If my performance were an issue, I'd expect my boss to speak with me directly and frankly before involving others. Maybe this student actually has had a real job before, and thus thought calling in was the appropriate way to handle his inability to work for the day.
But he's a student, so he's not allowed days off--okay. That's what he signed up for. But I'm surprised that you are 1) so disturbed by his behavior and 2) have the time/energy/desire to spend so much effort following up on, from what I understand from this thread, was one incident.
I think surgery residents would be the first to admit that they have a stressful schedule that makes huge demands physically, mentally, and emotionally. I think surgery residents would also be the first to admit that not everyone has what it takes to handle those demands. I have seen residents become almost personally offended when medical students don't have the same toughness that they do. But this is a required two-month rotation, and it's their first experience with this lifestyle. Obviously if it were a pattern, they're not holding up their responsibilities as a learner. But if the student called in one time, give him the benefit of the doubt. Don't contact the clerkship director (which would result in failing at my school) unless you truly think this one incident means he's totally unfit for medicine (or if there were other reasons beyond this to support that). If you feel so strongly about it, talk to him one-on-one about your expectations. If you think it's necessary, tell him when to come in and make up the hours.
And even if he did oversleep and THEN called in--I understand the offense is more egregious in that case, but man, have you never overslept before?
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So did you read the thread? Because all your questions are answered in it.
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I definitely don't agree with the system and believe that we are losing the importance of third year, but unfortunately USMLE scores are the most important thing in the world.
Sure, all the experiences are great and will help you become a better doctor, but it's easier to explain away a poor rotation evaluation than a poor Step 1.
