How many patients should a student be seeing?

[sylvanthus]

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Question for the academic people out there. I am currently at a non-teaching hospital doing my core EM rotation and am just curious what a good goal is for number of patients to see in an hour. Roughly speaking anyhow. I know many physicians seem to aim for 2ish an hour. Should I be hitting 1 an hour as a student? More, less?


Thanks in advance. Just trying to see if I am being efficient enough.

 

[gro2001]

Question for the academic people out there. I am currently at a non-teaching hospital doing my core EM rotation and am just curious what a good goal is for number of patients to see in an hour. Roughly speaking anyhow. I know many physicians seem to aim for 2ish an hour. Should I be hitting 1 an hour as a student? More, less?


Thanks in advance. Just trying to see if I am being efficient enough.

Especially for a student, Quality > Quantity. I think most everyone would rather have you see fewer patients but do a really good job.

For comparison, towards the end of intern year I was seeing slightly more than 1 pt per hour (that's in a place where there is a separate fast track and RME area where they filter out some of the lower acuity/quick dispo people). Almost twice as much in urgent care. I think for a student, if you are doing half of that, thats excellent.

 

[Daiphon]

Question for the academic people out there. I am currently at a non-teaching hospital doing my core EM rotation and am just curious what a good goal is for number of patients to see in an hour. Roughly speaking anyhow. I know many physicians seem to aim for 2ish an hour. Should I be hitting 1 an hour as a student? More, less?


Thanks in advance. Just trying to see if I am being efficient enough.

Agree. Quality >>>> quantity.

If it's a community shop, keep in mind that moving patients is a lot more important than in an academic setting... plus, no residents to diffuse the work. As such, knowing a few patients inside out will help more than trying to see the whole room.

That being said, volunteer for *every* procedure... no residents = great opportunity to do stuff. Plus, it'll free up your attendings to keep up with the room. I can see several patients in the amount of time it takes a student to do a lac, LP, etc...

Have fun!!!!
-d

Sent from my DROID BIONIC using Tapatalk

 

[sylvanthus]

Thanks for the replies. I am at a community hospital with no residents, so we are basically just trying to move the meat and stay afloat. I am definately jumping on all procedures that I can since there is noone else really around. Ive been seeing roughly 10 patients in 10 hours, but will possibly slow down a bit to improve quality and thoroughness.

Thanks guys.

 

[SoCuteMD]

It doesn't really matter how many patients a student sees. As someone who supervises them regularly, I much prefer if they pick up a patient, get a good history and physical, come up with a plan and put it in motion, document thoroughly and, only once all that is done, pick up another patient. I prefer them to have a light patient load and be able to stay on top of their patients and results as they pour in. If they don't, I don't feel compelled to chase them down to inform them of what's going on with their patient, what needs to be done next and how to do it - I just end up doing it myself.

 

[alreadylernd]

Agree. Quality >>>> quantity.


-d

Sent from my DROID BIONIC using Tapatalk

Remember that applies to your own education as well. Don't waste your time with the easy stuff on the community rotation - pick up the sickest patients, the interesting complaints that you might not get a lot of exposure too (eyes, derm, ortho or whatever) and skip over the twelfth chest pain, the chronic abdominal pains etc...

 

[Arcan57]

Remember that applies to your own education as well. Don't waste your time with the easy stuff on the community rotation - pick up the sickest patients, the interesting complaints that you might not get a lot of exposure too (eyes, derm, ortho or whatever) and skip over the twelfth chest pain, the chronic abdominal pains etc...

Depends, is sylvanthus going into EM? If so, cherry-picking interesting patients and carrying a light patient load gives a completely unrealistic look at what EM is as a specialty. If you don't do a least one rotation where you're carrying 3-4 patients at a time, then you have a view of EM that is almost 180 degrees to reality. I'm not saying every shift has to work you to your limit, but you need to know if you still like EM when it's run-of-the mill complaints and you don't have time to bond with the patients in any meaningful way.

If you're not going into EM, cherry-pick exclusively, know everything about the 2 patients you're carrying and spend most of your time wandering around looking for cool stuff to happen.

 

[sylvanthus]

Definately going into EM and applying pretty soon actually.

 

[sylvanthus]

Perhaps this rotation ill focus more on thoroughness and quality and then pick up the pace a bit more on my audition rotation next month.

 

[dotcb]

I recommend students and interns I work with to shoot for one patient an hour

 

[alreadylernd]

Depends, is sylvanthus going into EM? If so, cherry-picking interesting patients and carrying a light patient load gives a completely unrealistic look at what EM is as a specialty. If you don't do a least one rotation where you're carrying 3-4 patients at a time, then you have a view of EM that is almost 180 degrees to reality. I'm not saying every shift has to work you to your limit, but you need to know if you still like EM when it's run-of-the mill complaints and you don't have time to bond with the patients in any meaningful way.

If you're not going into EM, cherry-pick exclusively, know everything about the 2 patients you're carrying and spend most of your time wandering around looking for cool stuff to happen.

I'm not talking about picking patients to bond with, I'm talking about cherry picking charts that benefits learning. Abdominal pain should be a pretty straight forward workup by your second year of residency (I'm assuming an EM resident). Same for things like Headache, or chest pain. I think when you're not expected to be moving meat (like at the main shop, as a senior resident - which certainly has it's own learning benefits), you should try and pick up patients with complaints you might not be that comfortable with - do all the fracture reductions, look at all the eye complaints etc. And see how things are done in the community when you don't have every consultant in house at your fingertip.

 

[Arcan57]

I'm not talking about picking patients to bond with, I'm talking about cherry picking charts that benefits learning. Abdominal pain should be a pretty straight forward workup by your second year of residency (I'm assuming an EM resident). Same for things like Headache, or chest pain. I think when you're not expected to be moving meat (like at the main shop, as a senior resident - which certainly has it's own learning benefits), you should try and pick up patients with complaints you might not be that comfortable with - do all the fracture reductions, look at all the eye complaints etc. And see how things are done in the community when you don't have every consultant in house at your fingertip.

Yeah, the above advice was for students going into EM not residents. I will say that picking up a decent number of the chronic pain/malingering/conversion patients in my pod as an R4 ended up being useful in the community. The way I look at it is that dispo'ing every patient is a puzzle, and the more times you solve a puzzle the better you get at solving similar puzzles. Things like how to get rid of the gastroparesis trolls (a suprising number can pass the PO challenge of a percocet and thus are ready for dispo) or dealing with the sickler with multiple visits (max q30x 2 doses of meds in ED then either admit to heme or go home).

If there is interesting pathology or something you haven't dealt with much then pick them up. That's clearly more beneficial to your education. But if it's the choice between the painful to deal with patient and the run of the mill CP, take the painful patient.

 

[NinerNiner999]

Your goal as a student should be to maximize your learning time in the ED. I suggest to my students that instead of setting a goal for total number of patients, set a goal for new lessons learned daily, whether these are your actual patients or not. In general these are pretty reasonable guidelines:

2-3 procedures per shift (lac repair, abscess I&D, LP, etc) depending on the level of comfort of your attending and their time to supervise.

2 Critical Patients per shift with the preceptor (shadow, observe, and work on presentation).

The remaining time should be spent learning about those things you have not seen before, including those being managed by other people. Don't get in the way, but learn by watching. You have been given two ears and one mouth - use them proportionally.

Your biggest goal as a student should be to get a real handle on the top 20 EM complaints (Chest Pain, CHF, Abdominal pain, sepsis, etc) and have a framework for why and how to work these patients up. You should also focus on communicating these as efficiently as possible, using as many "buzzwords" as possible to get your point across to those listening to you.

Pay special attention to how the attending or preceptor communicates with consultants and admitting physicians - this will give you a good goal to aim for.

Try to present all of your patients in two brief sentences or less, using pertinent language as much as possible. I.E. "Room 4 is an 86 year old lady with abdominal pain, nausea, vomiting, diaphoresis, and pain out of proportion to examination. I'd like to order a CT, Lactate, keep an eye on her pressure, and have you take a look." or something along those lines. Then, you can listen to the attending present the patient to the surgeon using even less verbiage "I have a lady here with ischemic bowel." That's a great way to tie it all together...

 

[McGillGrad]

It doesn't really matter how many patients a student sees. As someone who supervises them regularly, I much prefer if they pick up a patient, get a good history and physical, come up with a plan and put it in motion, document thoroughly and, only once all that is done, pick up another patient. I prefer them to have a light patient load and be able to stay on top of their patients and results as they pour in. If they don't, I don't feel compelled to chase them down to inform them of what's going on with their patient, what needs to be done next and how to do it - I just end up doing it myself.

Exactly.

 

[jbar]

I think you also need to be aware of how much work you seeing a patient makes for your attending. Now in some places the med students can put in orders, do the whole chart, and the attending just needs to sign off on it. That's one situation. I've also rotation places where we weren't allowed to do any charting, do any ordering, and didn't have access to the computer to check labs and x-rays. So every patient I picked up made a lot more work for the attending (compared to having a resident see that patient). If you are in somewhere like that I would splint my time between having my own patients and doing stuff with the residents like see them manage a patient, do procedures with them etc. Maybe not as much fun as having your own patients but there may be rotations where they don't want you to have 6 patients a shift as a med student.

I would also say that you need to be 100% on top of your existing patients as a med student before you pick up another one. So if your patient needs a lac repaired, needs the notes done, needs you to track down what happened to their labs, all of that should be done before you pick up another one.

 

[VienneseWaltz]

I would also say that you need to be 100% on top of your existing patients as a med student before you pick up another one. So if your patient needs a lac repaired, needs the notes done, needs you to track down what happened to their labs, all of that should be done before you pick up another one.

Yes! We are not at all impressed if you come to us with three half-done patients. At my hospital, students (including sub-Is) cannot document or put in orders, and coming to me with three half-cooked patients for me to now manage primarily, especially when I am single coverage, will not endear you to me.

The emphasis here of quality over quantity is paramount.

 

[Groove]

Question for the academic people out there. I am currently at a non-teaching hospital doing my core EM rotation and am just curious what a good goal is for number of patients to see in an hour. Roughly speaking anyhow. I know many physicians seem to aim for 2ish an hour. Should I be hitting 1 an hour as a student? More, less?


Thanks in advance. Just trying to see if I am being efficient enough.

No more than 2 at a time.

 

[Aesculapius]

As a new intern, I would say 1 an hour is probably too much as a student. I consider myself decently fast for my level, and at the beginning of the year here, that's already not that easy to achieve given that I have to put in orders, make calls to PCPs and consults, do dispositions, chart, etc. I am sure that I will improve over time (many of the things that slow me down are logistical/system issues that I haven't learned yet) but given that as a student you probably don't have the ability to do many of these things (or if you do, it has to be closely supervised), the attending ends up having to do a lot of repeat work. I would agree with Groove that following 2 patients at a time is probably appropriate, unless one of them is in a holding pattern for whatever reason, in which case picking up another one is fine. Just make sure that you know everything that is going on with your patients at all times, if possible.

 

[sylvanthus]

I think you also need to be aware of how much work you seeing a patient makes for your attending. Now in some places the med students can put in orders, do the whole chart, and the attending just needs to sign off on it. That's one situation. I've also rotation places where we weren't allowed to do any charting, do any ordering, and didn't have access to the computer to check labs and x-rays. So every patient I picked up made a lot more work for the attending (compared to having a resident see that patient). If you are in somewhere like that I would splint my time between having my own patients and doing stuff with the residents like see them manage a patient, do procedures with them etc. Maybe not as much fun as having your own patients but there may be rotations where they don't want you to have 6 patients a shift as a med student.

I would also say that you need to be 100% on top of your existing patients as a med student before you pick up another one. So if your patient needs a lac repaired, needs the notes done, needs you to track down what happened to their labs, all of that should be done before you pick up another one.

Question about this. Oftentimes labs will be pending and I dont want to sit around waiting for these lab results if I can jump on and start a new patient and then keep an eye our for the lab results/CT/Etc to update. Really recommend waiting around till everything is back?

 

[StevieStud]

Question about this. Oftentimes labs will be pending and I dont want to sit around waiting for these lab results if I can jump on and start a new patient and then keep an eye our for the lab results/CT/Etc to update. Really recommend waiting around till everything is back?

Sounds like reading time to me.


Remember, at this stage of the game, it is all about quality versus quantitiy. It is nice to jump into the next patients but sometimes those patients are more complex than they first appear. Ultimately you end up trying to juggle two patients and providing neither patient with the quality of care they deserve (or the quality of care that you desire to reflect back upon you). Don't worry, there will be enough times in your future when you are forced to juggle multiple patients.

 

[jbar]

Question about this. Oftentimes labs will be pending and I dont want to sit around waiting for these lab results if I can jump on and start a new patient and then keep an eye our for the lab results/CT/Etc to update. Really recommend waiting around till everything is back?

By track down the labs I mean being aware that the order was put in 2 hours ago, and the results aren't back. ( yes, labs can take this long. But if you have a good computer system you should be able to see at what point the labs are at in their processing. Ie has the nurse drawn them? Are they received by the lab? Did the lab lose them?

I'm not saying you need results back before you see the next patient. But you don't want to be picking up patient number four and have the resident go "hey, why is this guy sitting here waiting for 5 hours for that second troponin, it's all we need to discharge him. Did they get drawn?" And have no idea.

You should be scanning your list of patients every time you sit down at the computer and ask yourself "what does this patient still need done to be admitted/discharged." And "is there something I could be doing to make those things happen."

If the answer for all your current patients is no, that patient 2 is at CT scan, patient 1 is waiting 2 more hours for the repeat troponin, patient 3 is currently being seen by the GYN consult, and all three notes are written; that's when it's time to pick up patient number 4.

 

[sylvanthus]

Answered my question perfectly, thanks.

 

[dally1025]

I prefer them to have a light patient load and be able to stay on top of their patients and results as they pour in. If they don't, I don't feel compelled to chase them down to inform them of what's going on with their patient, what needs to be done next and how to do it - I just end up doing it myself.

When I did my home rotation occasionally I would go off to assist/do a procedure and then called called in by a resident to see/do something else and when I returned the attendings had already dispo'ed my patient(s). It didn't happen every shift or anything but I always felt bad when I got back and realized the patient had already been sent home. However, I didn't want to say no if the residents gave the opportunity to do a procedure. When the attendings were around I told them where I was going but often I couldn't find them. If this happens on occasion is this seen poorly?

 

[VienneseWaltz]

When I did my home rotation occasionally I would go off to assist/do a procedure and then called called in by a resident to see/do something else and when I returned the attendings had already dispo'ed my patient(s). It didn't happen every shift or anything but I always felt bad when I got back and realized the patient had already been sent home. However, I didn't want to say no if the residents gave the opportunity to do a procedure. When the attendings were around I told them where I was going but often I couldn't find them. If this happens on occasion is this seen poorly?

No, we know if something big is going on in the department, and if we weren't the ones who told you to go see the code/chest tube/etc, we figure that's where you are and are glad that you are doing something probably more educational than discharging your nonpregnant vag bleeder. As long as we don't see you checking Facebook or sitting around looking bored, we will not judge you for seeking educational experiences outside your personal census--in fact, this is encouraged.