guidelines for invasive procedures by students?

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May 28, 2000
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I was surprised to find that we have no written policy or formal training requirements for lumbar punctures and comparably risky procedures. Basically, fresh 3rd year students can do LPs on any patient as long as the resident allows.

The issue came up regarding a student who was ordered by a resident to do an LP on an uncooperative pediatric patient with suspected meningitis. The student had seen two LPs, but never done one. (The student refused. No, it wasn't me.)

Does your school have a written policy, training requirements or restrictions on procedures performed by students? Are 3rd year students allowed to do heart transplants if the surgeon allows? (Sorry - just taking the argument to a logical extreme.)

Surely there is some formal policy at most schools. Yes?

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The only written policy at my school that I was able to find is as follows:

California state law allows specific exceptions for medical students to the general code, which requires that all medical acts must be performed by licensed physicians. The exception specifies that a student may do all things that a physician may do with the following two provisos:

That any medically-related activity performed by students be part of the course of study of an approved medical school.

That any medically-related activity performed by students be under the proper direction and supervision of the faculty of an approved medical school.

Medical students may write orders for drugs, treatments, etc., providing:

The provisions of number 2 above are observed.

The students are assigned to or are consultants to the service on which the order pertains.

A licensed physician countersigns all orders before the orders are executed. Telephone orders of counter-signatures will be accepted from licensed physicians (including licensed housestaff). Medical students may locate and solicit the licensed physician's verification by telephone, but the licensed physician must speak directly to the registered nurse and must actually sign the order before going off duty. The counter-signature is recorded as a telephone order. Routine admission orders are not exempted from the above provisions.

Medical students may act as subinterns, but they are still subject to the above provisions.

Medical students will identify their signatures with CC (Clinical Clerk), just as licensed physicians identify their signatures with MD. Medical students will also wear badges identifying them as medical students.

Students functioning in a preceptorship away from the Stanford University Hospital and its affiliates are subject to the above limitations. If a preceptorship is an out-of-state one, other state regulations may govern the role of the student in the preceptorship, and students should ascertain the provisions of these regulations.

I think that the policy varies state to state according to state law. But I guess as long as the med student has "proper supervision" (the details of which is open to debate), that they theoretically can perform open heart surgery. Although it would really never go that far... ;)
so if the student did it and something went wrong, who would own the liability?

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The student that refused should obviously go into a non procedure oriented specialty. After watching two LPs, the student should have read about the procedure and been prepared to do one. Everyone must do their "first" of a procedure. With the proper guidance, there should be no problem.

If you are afraid to do a procedure or refuse to do one, it shows that you do not have the drive to read about how to do them and your residents will never offer another LP, thoracentesis, etc. to you. YOU WILL MISS OUT BECAUSE OF YOUR FEAR. Buck up and try a procedure.

I know you were just asking about a written procedure, but your "example" is what I am talking about. By the way, liability in medical education is generally in the hands of the attending physician. The resident or student cannot be sued but their staff MD can be.
Sorry, I disagree. I think it is foolish to have a 3rd medical student do their first LP on a Peds patient. I have done LPs in the past and let me tell you, it can be challenging enough on an adult, let alone a squirming, non-compliant child. Where I trained as a PA, procedures were first done on adults, then Peds. IMHO, thats how it should usually go. The "See one, Do one, Teach one" mentality is archaic & wreckless, at best.

Finally, I don't think any real conclusions about this individual can be made, especially an MS-III who is still green and new to medicine. We have no idea what was going through that person's mind at the time. At least they had the guts to stand up for what they believed was the right thing.