Are med students at most schools allowed to put in orders?

[voxveritatisetlucis]

On every clerkship success guide I’ve read, it says that one way for medical students to be helpful is to put in orders for patients on behalf of residents. However, I’ve never heard of any student at my school doing this nor has a resident ever asked me. Is this just like an academic medical center thing?

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[LucidSplash]

Some EMR allow students to enter orders but then send them to a co-signer, who can just accept the orders. Some do not have this feature or the institution does not allow it. Also some clerkship guides may be based on a long departed era of paper orders that a med student could write out the orders, such as admission orders, and then the resident just physically signed them.

 

[AnonymousDoctorGuyPerson]

On every clerkship success guide I’ve read, it says that one way for medical students to be helpful is to put in orders for patients on behalf of residents. However, I’ve never heard of any student at my school doing this nor has a resident ever asked me. Is this just like an academic medical center thing?

No need to read a clerkship guide let alone multiple different ones - just be affable and available and you're done.

As for orders, med students at some institutions can pend orders and then a resident can just sign them. It takes more work for a resident to do this as it's very easy for med students to enter in orders incorrectly, and orders take me like 0.03 seconds to do. I also have order sets for everything so they're present to how I want them.

Call a consult? Sure, that can be helpful. Placing the consult order? Rather just do it myself.

 

[voxveritatisetlucis]

No need to read a clerkship guide let alone multiple different ones - just be affable and available and you're done.

As for orders, med students at some institutions can pend orders and then a resident can just sign them. It takes more work for a resident to do this as it's very easy for med students to enter in orders incorrectly, and orders take me like 0.03 seconds to do. I also have order sets for everything so they're present to how I want them.

Call a consult? Sure, that can be helpful. Placing the consult order? Rather just do it myself.

Consultants at my school’s hospitals get angry when residents call them, I’d imagine they’d lose their mind if a med student called them

 

[Hollow Knight]

We do at my institution, but I think that's a rarity these days.

Edit: also, this isn't an ivory tower, I'm in the woods out here. This hospital is a zoo. Probably why I get away with doing more because the residents/attendings are overworked and could really use the extra slight bit of help

 

[Lost in Translation]

I used to try to teach my students how to pend or put in orders so they can get the experience, maybe 30% of them actually pay attention to what I’m trying to show them and of those maybe 25% of them get it right.

I’ve since stopped trying unless a student themselves asks to be taught.

 

[NITRAS]

Consultants at my school’s hospitals get angry when residents call them, I’d imagine they’d lose their mind if a med student called them

Sorry, what? A resident should be able to call a consultants. How else are they suppose to learn?

 

[voxveritatisetlucis]

Sorry, what? A resident should be able to call a consultants. How else are they suppose to learn?

Of course they are allowed to call consultants but the consultants don’t like it very much

 

[FlowRate]

This is now 8 years ago, but we could place orders on our "acting internship." The orders still had to be cosigned by our senior resident, but we placed all the orders for all the patients. We could also give verbal orders during rapid responses and that didn't have to be cosigned by the senior.

 

[AnonymousDoctorGuyPerson]

Consultants at my school’s hospitals get angry when residents call them, I’d imagine they’d lose their mind if a med student called them

That's their problem. Just call em and ask your question, don't take to heart how they react.

It was similar at my institution, personally I didn't do the cop out of saying "I'm the med student" is call and say

"Hey this is Anonymous with the So and So Team" - know the patient, know the question, speak clearly and confidently.

And if they yell, they yell, you did your job


Fortunately in residency consultants are super nice, and outside of surgery we don't even call it's all done through secure chat outside of urgent requests.

 

[Dral]

I'm not condoning the 'angry when called by med student', but where I trained we had a fairly strict template to follow when we called a consult:

Hi, this is so and so with X team.
We have a pt so and so, MR #.
They were admitted for X (one sentence).
Their relevant problem is this (one sentence).
Our question is this (one sentence).

Even as an intern, I learned that quickly and knew it all year. I think med students called once in awhile, but with them rotating through monthly, there are more of them coming through with a higher chance of them not learning it correctly or deviating from the template. Again, not condoning the anger part, but trying to put out a side for why med students might not routinely be calling in consults (if that is the system that is used).

 

[mrbreakfast]

As an consultant attending in an academic center, I do not want to be called by medical students. I understand the training aspect, that is fine. I consider it a little insulting that a team picks their lowest member of the totem pole to call me, but I also understand they don't always know who they're paging. I can live with that.

As @Dral put it, calling a consult follows a simple template: why are they here, what's the relevant information, what is your specific question for me, all presented concisely. The issue with med students calling is that there's a low chance I'm getting that from an intern and a near-zero percent chance I'm getting that from a med student; and, a low chance someone on the team who is not an intern or a med student is listening in to correct them. What I'm getting in reality is a 5-minute story about the patient's general PMH from someone who honestly has no idea why their senior or attending told them to call me.

I will still see a consult even when the person calling me has zero idea why they're calling me or what the question is (happens all the time in July). I can go fishing and try to figure out what the team wants. But what I can't have is the senior or attending calling me later in the day saying "hey, sorry, I think our question wasn't properly conveyed, can you go see the patient again?" because the answer is "yeah, maybe tomorrow or the next day, if I have time." Our service is designed to see the vast majority of our consults a just single time. These "corrections" happen multiple times/week and affects patient care.


tl;dr in medicine, if you order the wrong test or wrong scan, you may not get the answers you were looking for. If you ask me to see a patient for "an evaluation" or "my thoughts," I'm going to default to my specific job at the hospital, which is to identify whether the patient is experiencing an acute, life-threatening emergency, and that's what I'm going to comment on, and potentially nothing else. You can let your med student order a test, or a imaging study, or a consult, but regardless of what it is, someone needs to make sure the order is correct.

 

[FlowRate]

As an consultant attending in an academic center, I do not want to be called by medical students. I understand the training aspect, that is fine. I consider it a little insulting that a team picks their lowest member of the totem pole to call me, but I also understand they don't always know who they're paging. I can live with that.

No trainees in your specialty where you work?

I did all my training in mega-centers, and a few months in a small community site with almost no actual consultants, so my frame of reference is entirely med students calling a resident/fellow for a consult, not an attending.

It's on the primary team to ensure the med student is sufficiently briefed as to why/how to call the consult and to have someone there who can help if they don't know something. That's feedback that I would hope could be relayed on all sorts of levels as needed.

 

[operaman]

I think time of day plays a huge role too. If someone is waking me up at midnight, it needs to be someone senior who can convey the issue and question succinctly. Otherwise I do the “is your attending near by? Can I speak to them please?”

During regular hours I’m a lot more patient and willing to walk a student or intern through the consult conversation. Everyone has to learn, though in theory the seniors on the team should be doing practice calls with them before setting them loose.

The other issue is that some people just suck at calling consults even as attendings. I’m convinced these are the people who blew off rotations outside their chosen field in med school so they never really got a sense of how other services think. The good ones who call me seem to have some sense of what I do and have very clear questions about patients with problems that only my field can treat. The bad ones end up being more “hey man, this guys got an ear and a nose…maybe a throat, I don’t know I haven’t actually seen him yet. But yeah uh we wanted to get you on board to help manage those…”

 

[Redpancreas]

Consultants at my school’s hospitals get angry when residents call them, I’d imagine they’d lose their mind if a med student called them

@mrbreakfast

That's a good description. It's interesting because, at one place I worked, consultants literally relied on what was typed in the 'consult for' box in the Epic Order. Every month, residents had to be reminded to type coherent phrases in there because they were often so focused on putting in the orders during rounds. The same issue occurs when ordering imaging for radiology. Unless the consultant or radiologist knows what they're looking for, the consult is almost useless.

OP, if the residents encourage calling consults, I strongly advise you to try it. This is an essential communication skill to develop early in medical training. Do it under their supervision so that you can receive feedback and ensure that the correct information is conveyed to the consultants. Be sure to understand why the consult is being called, and clarify with the residents after the attending leaves, as they sometimes provide useful context (e.g., this is more "defensive medicine" than anything else which can influence your approach during the call).

Before calling, run through what you're going to say in your head to ensure it flows and makes sense. Use SBAR (Situation, Background, Assessment, Recommendation). Start with why the consult is being called to give the consultant an idea of what details focus on. Then, explain why the patient came in and what’s happening now. Provide only the necessary background (ex.) pertinent history and labs), followed by an assessment (your concern, what your team has done, and what you want their opinion or help with). Let the consultant ask questions and provide their assessment and recommendations. Every medical condition has different key points to include, which you'll learn through experience on these rotations.

ACS example:

'We're calling regarding our concern for NSTEMI. The patient is a 65-year-old male who presented with 8 hours of persistent chest pain, relieved with rest and nitro. Troponins are 0.3 and 1.2. He has poorly controlled diabetes, smokes, and has hypertension. His father had an early MI. The EKG shows localized ST depressions in the anterior territory. We have loaded antiplatelets, started heparin, a beta-blocker, and a statin, but we're concerned about active cardiac ischemia and believe the patient may need an urgent cath. We wanted your opinion and recommendations.'

You're going to make mistakes, be interrupted, or corrected, and a resident may even take the phone away from you. That’s part of the learning process, so be attentive and learn from your mistakes. Even if you do everything perfectly, you may still get pushback because it could be a a ****ty consult that you were asked to call or because the consultant is overwhelmed. Learn to take it in stride.

 

[Lost in Translation]

(e.g., this is more "defensive medicine" than anything else which can influence your approach during the call).

Nothing pisses me off more than an attending telling me to call a consult to a service that really does not need to be involved.

"Hey, thanks for calling back, my attending wants a consult on this patient with [blah blah blah]."

 

[mrbreakfast]

No trainees in your specialty where you work?

On the contrary, I have a huge squad of residents including a senior who on in theory is supposed to be holding the pager, and in theory the residents who are assigned a consult are supposed to call it back. In practice the interns/juniors do a bad job of calling back, and we have such high volumes that I often have to take the pager, especially when we have an outpatient-minded senior (not great for education, I know, our dept is working on solutions). Overall I end up having to call a large percentage of consults back myself. So that's why I don't get mad if some med student calls me, they don't know who they're paging - if they directly page me, though, that's a different story.

But this actually further emphasizes my point. If I call a consult back and get a vague story, I know what questions to ask. If a junior/intern does and gets the "my attending wanted you to see this patient," that's the end of the conversation, and when they staff with me later, now we have no idea what's going on.

I'm just complaining here, but what I would say in summary is that I would be fine hearing an excellent presentation or consult call from a medical student. It's the primary team's job to help make that happen.

 

[mrbreakfast]

Nothing pisses me off more than an attending telling me to call a consult to a service that really does not need to be involved.

"Hey, thanks for calling back, my attending wants a consult on this patient with [blah blah blah]."

The biggest issue with this is people consulting for outpatient issues. "Patient needs to see a subspecialist in your specialty but there's a long wait list, can you see them inpatient?" No, because I'm not a subspecialist and we're only supposed to be seeing acute issues. If you want me to put that in the chart in a consult note, fine, but what teams don't think about is the bill patients get for me seeing them for 5 minutes.

 

[Redpancreas]

The biggest issue with this is people consulting for outpatient issues. "Patient needs to see a subspecialist in your specialty but there's a long wait list, can you see them inpatient?" No, because I'm not a subspecialist and we're only supposed to be seeing acute issues. If you want me to put that in the chart in a consult note, fine, but what teams don't think about is the bill patients get for me seeing them for 5 minutes.

I think patients should be given a cost estimate for every order placed so this can be brought up in real-time. The problem's that no one is willing to open themselves to that level of transparency when their competitors aren't as it would lead to huge profit losses. Most academic centers are already struggling to get by because doing what's indicated to care for a hospitalized patient is not profitable.

 

[mrbreakfast]

I think patients should be given a cost estimate for every order placed so this can be brought up in real-time. The problem's that no one is willing to open themselves to that level of transparency when their competitors aren't as it would lead to huge profit losses. Most academic centers are already struggling to get by because doing what's indicated to care for a hospitalized patient is not profitable.

Don't want to get massively off-topic but for the average inpatient, by far the most expensive aspect of being hospitalized is the bed they're sitting in; "room and board," so to speak. We do discuss costs with patients occasionally because strangely enough, in my experience, a large percentage of out-of-pocket patients refuse bedside lumbar punctures because they assume it's going to cost a lot. I have no idea what it costs but it can't be much, and try to tell them that. But we could talk about hospital costs and academic expenses all day.

All I'll say is that an inpatient consult should affect the patient's hospital course, i.e. make it shorter or achieve a better outcome. Teams will consult us for cognitive assessments, or wonder if their patient here with AKI and CHF may have early Parkinsons disease, or for ET, or something else. I'm not sure what the teams expect, but nothing I say or do is going to get the patient out of the hospital faster. Obviously I'm not complaining loudly because I'm getting paid per consult, but it's one of the big downsides of the ivory academic towers of medicine.

 

[Redpancreas]

Don't want to get massively off-topic but for the average inpatient, by far the most expensive aspect of being hospitalized is the bed they're sitting in; "room and board," so to speak. We do discuss costs with patients occasionally because strangely enough, in my experience, a large percentage of out-of-pocket patients refuse bedside lumbar punctures because they assume it's going to cost a lot. I have no idea what it costs but it can't be much, and try to tell them that. But we could talk about hospital costs and academic expenses all day.

All I'll say is that an inpatient consult should affect the patient's hospital course, i.e. make it shorter or achieve a better outcome. Teams will consult us for cognitive assessments, or wonder if their patient here with AKI and CHF may have early Parkinsons disease, or for ET, or something else. I'm not sure what the teams expect, but nothing I say or do is going to get the patient out of the hospital faster. Obviously I'm not complaining loudly because I'm getting paid per consult, but it's one of the big downsides of the ivory academic towers of medicine.

100% that this should be the goal.

You have to create a penalty for inappropriate consults to get to that. Otherwise, hospitalists will continue to abuse the standards/systems to maximize their individual metrics.

Why is the consult being called in the first place? Every case is different. Sometimes it’s medico-legal from the physician, sometimes it’s for patient satisfaction, sometimes it’s nurse satisfaction/reassurance (sadly), sometimes it’s also lack of critical thinking/understanding. Instead of breaking through the barriers, it’s much easier to just consult.

Ultimately the hospitalist has to produce tangible results. Poor reviews from nurses/patients hurt. Also, the one case that was missed or patient was readmitted because XYZ was on board irregardless of whether that would have made a difference drastically outweighs the 1000 times the hospitalist was judicious and didn’t order something/consult someone.

 

[mrbreakfast]

You have to create a penalty for inappropriate consults to get to that. Otherwise, hospitalists will continue to abuse the standards/systems to maximize their individual metrics.

Sure, but what defines an inappropriate consult? That patient with mild rigidity may have early Parkinsons; they also may have ALS, CJD, or myelopathy. Encephalopathy is just that, until it's subclinical seizures. Most older adults have facial asymmetry for a plethora of reasons, but some of them have it because they just had a stroke. Etc. And it goes both ways. I very occasionally attend on a primary service. Now, I can look up how to treat SIADH, or afib with RVR, or pseudomonas, and learned how to treat those in the past; it's been quite some time for me, though, and I would appreciate medicine assistance. Are those inappropriate consults? That probably depends who you ask. I tell my residents that we do our job and let others do theirs; a disruption of that balance inevitably leads to complications.

There will never be a penalty for inappropriate consults, because 1) the billing I generate from "inappropriate" consults alone easily pays my salary, and 2) because regardless of the circumstances, a malpractice case where a consultant could've been consulted, but wasn't, is going to focus on - and potentially hinge on - that singular fact.

I'm a neurohospitalist. I believe Dr. Glaucomflecken made the joke in one of his videos that neurohospitalists have jobs because medical students don't pay attention in their neuroscience block, and for the most part, that's about half of why the hospital pays me. A significant proportion of my job is doing neuro exams for teams of doctors who will freely admit they don't know how to do one (and neither does AI). And that's just my field. Humans aren't perfect and neither is medical education, and for that reason, your friendly specialist consultant will always have a job.

 

[NotAProgDirector]

The consult culture may also be very different depending on the setting. I worked at a community site where every single patient admitted who was on levothyroxine would get an endocrine consult. When I pointed out that I didn't need one since the answer is "continue current T4 dose, no not check TSH while acutely ill as may be artificially suppressed by acute illness", was told to do it anyway. The endo doc apparently needed the billing.

 

[Redpancreas]

Sure, but what defines an inappropriate consult? That patient with mild rigidity may have early Parkinsons; they also may have ALS, CJD, or myelopathy. Encephalopathy is just that, until it's subclinical seizures. Most older adults have facial asymmetry for a plethora of reasons, but some of them have it because they just had a stroke. Etc. And it goes both ways. I very occasionally attend on a primary service. Now, I can look up how to treat SIADH, or afib with RVR, or pseudomonas, and learned how to treat those in the past; it's been quite some time for me, though, and I would appreciate medicine assistance. Are those inappropriate consults? That probably depends who you ask. I tell my residents that we do our job and let others do theirs; a disruption of that balance inevitably leads to complications.

There will never be a penalty for inappropriate consults, because 1) the billing I generate from "inappropriate" consults alone easily pays my salary, and 2) because regardless of the circumstances, a malpractice case where a consultant could've been consulted, but wasn't, is going to focus on - and potentially hinge on - that singular fact.

I'm a neurohospitalist. I believe Dr. Glaucomflecken made the joke in one of his videos that neurohospitalists have jobs because medical students don't pay attention in their neuroscience block, and for the most part, that's about half of why the hospital pays me. A significant proportion of my job is doing neuro exams for teams of doctors who will freely admit they don't know how to do one (and neither does AI). And that's just my field. Humans aren't perfect and neither is medical education, and for that reason, your friendly specialist consultant will always have a job.

Which I guess is why we all consult.

 

[esob]

When I was in medical school, it was similar to other posters' experiences, where medical students could enter orders and residents could release them. I think this is good practice, and I try to let all of my rotating students have an opportunity to enter orders.

 

[DarkBluMage]

I only put in orders a few times, but it was with my attending standing over my shoulder helping/teaching me.