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How am I supposed to work with a med student?

Discussion in 'Emergency Medicine' started by The White Coat Investor, Nov 12, 2005.

  1. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD
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    As a senior resident, I work about half my shifts with a 4th year medical student assigned to me. You'd think being a 4th year medical student would have prepared me to do this, but on not one of my three EM rotations as an MSIV did I work with a resident. I can't believe how much it throws off my rhythm. I get the everything from the super-duper gung-ho EM stud type to the "going into peds never done a procedure" type. I see probably 2/3 of the patients I would see on a regular shift. With the very best students it is a draw, they make up for the time I spend teaching them by taking care of the equivalent scut for me (lacs, checking labs, paperwork, taking the review of systems etc.) With a "bad" medical student, it takes me 3 times as long to let them do something (and I'm not just talking procedures) as to do it myself. Truly, medical education occurs only out of the benevolence of its practitioners.

    Any tips out there on how to work more effectively with studs?
     
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  3. NateatUC

    NateatUC Senior Member
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    From a current MSIV who's rotated at 3 different facilites this year, and thus, LOTS of different residents:

    I think your interaction with your student really depends on how many times you're going to work with them. The best residents I've worked with have, during our first shift, have taken the time to figure out just how competent I am, then give me the appropriate degree of autonomy. I think that's the biggest balance you have to strike. If you've got a student that is really gung ho, and you are comfortable with their skills, let them go at it. I consider myself to be pretty competent, and would get rather frustrated when I wasn't allowed to carry multiple pts at once, or actually see someone that may actually be sick. Obviously don't give us someone who's likely to crash, but someone who's stable with, say, chest pain or abdominal pain and might actually have something may be an interesting H&P and workup. And if you've got a student who's not so strong, or not as into the whole EM environment, just don't give them as much to do.

    Also, do you determine which patients the student sees, or is it always just the next pt in the box? If you do, try and find the educational cases, the ones with good ddx, etc. DON'T give us the frequent flier BS pts. Those are the folks that aren't educational and we, the pt, and the departent will all be better served by either you or one of the other residents just blowing the pt out.

    Another point: In my mind, some of the stuff you called "scut," the lacs, checking labs, ROS, etc. I see as necessary for me to do, as long as its for one of MY patients. Just don't have me running around checking labs for everyone else. And for me, if someone else has a pt with some sort of complex lac, and doesn't have time to deal with it, I'm always happy for the practice.

    And finally, most of us realize we slow you down. If you are just absolutely slammed, it may be in everyone's interest for you and the student to see patients together, with the the promise of teaching and the opportunity to see some pts on their own later on.
     
  4. Snoopy

    Snoopy Senior Member
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    As a senior resident and someone going into academics next year, the above post was extremely helpful. Thanks for some very good suggestions. It does get hard for us old fogeys to remember back to med school days. :laugh:
     
  5. AlienHand

    AlienHand Member
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    I'm a 4th year student doing my second EM rotation right now, and I often work with the 3rd year residents. I agree with most of what NateatUC said. I think that the fact that you're asking for suggestions means that you're already probably a pretty good mentor; the residents who aren't good with students probably would never ask.

    One of the residents on my current rotation took a few minutes on my first day to go over basic protocols for students, such as when to pick up more patients and other logistical points and expectations. This was appreciated. By laying down some ground rules, you can enable your students to focus more on patient care rather than wasting time wondering what they're supposed to be doing.

    Finally, I'd just encourage you to provide feedback to students. Ask questions. Pimping is okay, if the purpose is to educate. Give us the opportunity to let us show that we do, in fact, have a clue, even if we seem inept at times.
     
  6. beyond all hope

    beyond all hope Senior Member
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    It's well recognized that a med student is more work. I have the same dilemna and I'm going into academics so I need to be able to deal with it as well.

    Here are some things I do:

    1) with gung-ho students, you can give them a longer leash. Let them write the chart (except the HPI. I always write that myself). With other students, after each patient say: "go read up on X", then run around and get your work done while they're out of your hair.

    2) Make sure your students follow up on labs, films, etc. It's my experience that I end up doing all of that anyway, but it's something that they should do for their own benefit and it's an extra pair of eyes. They can also talk to the family, get old records, etc.

    3) I often go see the patient individually, do a super-quick H&P without touching a chart, order stuff, and then let the student present to me while I write the chart.
     
  7. Dr.Evil1

    Dr.Evil1 Senior Member
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    Have you never read "House of God" One of his quotes is "show me the medical student that ONLY DOUBLES my workload and I will kiss the ground they walk on" or something like that.

    I am just an intern so I don't get to spend alot of time in the department yet. I do work with TONS of medical students on the floors in my off service rotations though. I like teaching med students and when I'm not swamped with work post call at 29.5 hrs needing to do 5 more things before I can go home and sleep. At these times I have wanted to kill medical students even just for asking "is there anything I can do for you?"

    Medical students shouldn't take this as an insult though. You just have to figure out what needs to be done and do what you can. The more time you spend asking what to be done the more annoying you become to the residents. Just figure out what needs to be done and then tell, don't ask, the resident what you will be doing. Writing notes and getting things ready for procedures is really helpful on the floor. Also dealing with that annoying patient or family post call (I would buy you lunch for doing that) is a lifesaver.
     
  8. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD
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    Good tips all...sometimes it seems like yesterday, but 2 1/2 years has helped me forget just how much it sucked to have a horrible job that 1) I paid to do, 2) had no defined responsibilities, and 3) determined what residency I got into and what I did for the rest of my career. Don't get me wrong, being a medical student sucks. It was okay once, but I don't know anyone that would do it twice even for double-attending pay.
     
  9. bartleby

    bartleby Senior Member
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    A couple of tips:

    -Make your boundaries clear: Unstable vitals or sick looking patient means they come back out the desk and find you immediately, with no poor reflection on them as a consequence
    -Set a time limit: When you pick a patient for him or her to see, say something polite but firm along the lines of "Hmmm...pleuritic chest pain...this might be interesting. Why don't you go in and see her and meet me back at the desk in 10 minutes?" This frees them of the need to do a 45 minute H&P and helps keep the patient's workup moving along.
    -Time management: When the student is in going to see a patient, this is a great time to go see somebody else on your own primarily. You're probably going to make it out of the room faster and can get some orders done on the patient you just saw before the student gets out of seeing his/her patient. Then, you can do stuff like check xrays and labs together. This gives the student some face time with you and time for you to teach them something.

    While we're all stoked about teaching the students who are hot for an EM career, there is still a lot of value in an EM rotation for a future IM or peds doc. This is your chance to show them the new face of academic EM-trained ED docs. Plus, they have plenty of useful stuff to learn from you which can help them further along in their career.
     
    cbrons likes this.
  10. Annette

    Annette gainfully employed
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    I like the tips so far, even in an IM setting. One thing I like to do, is teach the patient and the student together. For example, the differential of chest pain. The patients like to hear what may be going on, and the student gets teaching at the same time. It is always rewarding to see that light bulb go off! :idea:
     
  11. emedpa

    emedpa GlobalDoc
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    I have taught fp residents, med students, and pa students for > 10 yrs. I work in a facility that bases our salary in large part on a production bonus and find that I always make more money the shifts I have a student. why you ask? while they are suturing the 20 cm 2 layer closure leg lac that takes them 30 + minutes I am off seeing other pts and earning more$$$. I am a big fan of the see one do one method so once someone has sutured a lac, removed an ingrown toenail, reduced a dislocated shoulder, etc I let them continue to do so to the extent of their competence. if they can't/don't want to do something they know they can ask me for help. folks who are er gunners I spend a lot of time with developing good ddx's, etc., for everyone else I think of it as a basic er procedures rotation and troll the chart rack for them for as many procedures as possible. some folks are there just to put in their time and leave. others want the best er rotation possible with a full range of pts and procedures. I try to tailor the rotation to the needs and desires of each student and give everyone basic review of common ekg's, xrays, etc
     
  12. Hawk22

    Hawk22 Senior Member
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    I'm a medical student and the most important things for me are"

    1. Feedback, feedback, feedback! I really want to improve my skills and abilities and nothing is more frustrating when a resident just tells you "you're doing fine" and can't give you anything to improve upon. Even if you have a perfect student (I'm by no means there), other advice like "focus on X" is greatly appreciated.

    2. Being up-front about expectations from the beginning. Be clear about what is off-limits for students to do at your institution. It is also very helpful when a resident says spells out what might happen when you really get slammed. Something like: "If we get hammered with patients, know that I might not have time for a whole lot of teaching right at that second, but we can come back to it when things calm down." This is especially important in the ED where things can go from dead to crazy in no time.

    3. Proper pimping. I really like when attendings ask questions and use it as an interactive way to teach, but there is a real art to this. The challenge is to ask in such a way that you're getting the student to think, but not sound like you're being combative or attacking them The best attending I ever had told me on the first day tha he asked alot of questions to students and not to worry if I didn't know the answers because the point was to teach me and not to hurt my evaluation (if I knew the answers, I wouldn't need to be a student). Overall, 50% of the questions were appropriate for a medical student at my level and the rest were more upper level things I would never know (but subsequently picked up). I learned a TON from him because of his approach.
     
  13. UCLA2000

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    As a 4th year medical student I can see how your situation would pose a problem. That being said, it is all med student dependent. Not all med students are created equally. I was trained at an east coast ivy and did several rotations at other institutes. I encountered a wide range of medical students at those institutes. Some were completely inept, and others were carrying the same workload as an intern.

    Perhaps a quick sit down is in order if you encounter a med student who is not pulling their weight. Straight up tell them that they need to get it together because they are creating more work for other people.

    I literally carried my ID services at my home institute. My colleague on ID was so inept that 3 different attendings approached me with concerns that she should consider an alternate career. Despite my daily reassurance to them that she was trying, and would get it together, she never did.

    They never had a sit down with her. Perhaps putting the fear of God in her would have lit a fire under her arse to pick up the pace.
    -------------------------------------------------
    Advice for residents:

    1. Please verify my orders in a timely fashion. The nursing staff makes my life miserable when my orders have been sitting around for 30 min. If they then go ahead and complain to the attending about my orders, I am going to look inept.

    2. If I can't present a patient, or pick up another while I am waiting to present, then my entire day goes to **** and I look bad to the attending because I only have 1,2, or even 3 patients.

    3. If you put in orders on my patient, please let me know that you did it. You obviously have much more experience than I do and there was a reason why you put the order in. I won't learn if I don't know that it has been done.

    4. If I've been doing a procedure for the last 30 min then please give me 5 min to catch up on my pts labs/radiology prior to asking me for findings. Of course I am not going to know what their labs/films showed. I'm not a mind reader.

    5. Please let me know if things are off limits. I have learned ask prior to doing absolutely anything. Just because I ask you if you're comfortable with me doing something does NOT mean that I do not know how to do it (or have not done it 100 times).

    6. If you tell me to do something and then the attending reprimands me for doing it later, then please sack up and tell him/her that you asked me to do it. Something as simple as me doing something that the attending feels is off limits could screw me in terms of grades, or a residency at an away rotation.

    7. Give honest feedback. Don't tell me that I'm the best med student you've ever seen and then give me a HP for a grade.

    8. If I tell you that a patient is sick, take it seriously. Although I do not have as much medical training as you do, I am not a TOTAL idiot. I can recognize respiratory distress as well as the next guy.

    9. Telling me that I function at the level of an intern is not a compliment at the end of my 4th year. It is to be expected. If I am not functioning at that level then I am going to be screwed in a few months.

    10. I am not your scut monkey. I am here to learn. That being said I am a team player and I am there to help out. If you are swamped, I will do my best to decompress you. However, please don't take advantage of this. I don't get paid for this.

    11. Med students get hungry too.

    12. Just because I am a med student please don't assume that I am younger, or dumber than you are. Non trads exist, and the title med student is a measure of training and not intelligence. Calling me "young man" "young doctor" or saying "good boy" is a good way to get a glare. It goes over especially well if I'm older than you are.

    damn I gotta go, going to be late for a date. Let me know if any of this is useful. If so I'll post more later.
     
  14. EctopicFetus

    EctopicFetus Keeping it funky enough
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    UCLA well said and quite funny. Keep it coming. Sadly, I think the people who are there to "teach" us are often busy. I realize that different places work differently. I did 2 4th yr EM rotations and presenting to an attending vs resident does make a big difference. That being said the #1 reason I was there was to get a LOR, some experience and learn. Now if you want to see me do something to throw it in my LOR let me know what you expect. If I dont know then what can I do about it. Dont be afraid of telling me where I can improve. I think at some point some MD students were way too sensitive but the only area for improvement that me and all my friends get is "read more". Everyone thinks this is a safe thing to say but it is worthless. Yeah I should read all of Harrisons and it would be great if I could. Heck reading all of Rosens would be awesome as well but lets be serious! I want to know if I should have a better DDx or other labs or improve my PE skills. Truth is everyone is busy so that makes things hard. Residents who show they care about me learning are the most appreciated. Peace! and Desperado I am still holding out on my U of AZ interview man! I hope I can get it!
     

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