How much are surgeons talking about med stud skills in OR?

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roinom

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I just wonder how the talk is going between surgeons about what is going on in the operating room. Outside, all surgeons can really see what a medical student does but in the operating room there is only one surgeons that can have a subjective opinion about how good the student is.

While I have been sitting around with the surgeons they can sometimes say "There will not be a surgeon of X, he is so clumsy when assisting" and so on..

My own experience as an example:

When I have been assisting different surgeons I get along really well with some of them and I actually got text messaged by on of the more technical surgeons (a guy in his young 40s who get a lot of difficult cases and is admittedly a good surgeon) that I'm doing really well in the OR. He also let me do a lot of things during surgery.

Anyway, there is another surgeon who really gets pissed when you're not doing things in his way. Even when I first operated with him, I always just answered "Ok, thanks for telling me" when he said "No,no no. Never do like that, always do like that" when I was taught differently by a another surgeon. And I'm never answering something along the lines of "No, this is how I do because X told me to do like this".

They seem to sometimes interpret is as a lie if they ask "Have you done this before?" and you answer yes and do it, then get blamed because you did not do it as they wanted, something you never could know since you never operated with them.

So, with these guys that are blamed as being "clumsy in the OR" is it something all surgeon thinks or is it enough someone is unhappy with the assisting from a med student?
 
roinom said:
I just wonder how the talk is going between surgeons about what is going on in the operating room. Outside, all surgeons can really see what a medical student does but in the operating room there is only one surgeons that can have a subjective opinion about how good the student is.

While I have been sitting around with the surgeons they can sometimes say "There will not be a surgeon of X, he is so clumsy when assisting" and so on..

My own experience as an example:

When I have been assisting different surgeons I get along really well with some of them and I actually got text messaged by on of the more technical surgeons (a guy in his young 40s who get a lot of difficult cases and is admittedly a good surgeon) that I'm doing really well in the OR. He also let me do a lot of things during surgery.

Anyway, there is another surgeon who really gets pissed when you're not doing things in his way. Even when I first operated with him, I always just answered "Ok, thanks for telling me" when he said "No,no no. Never do like that, always do like that" when I was taught differently by a another surgeon. And I'm never answering something along the lines of "No, this is how I do because X told me to do like this".

They seem to sometimes interpret is as a lie if they ask "Have you done this before?" and you answer yes and do it, then get blamed because you did not do it as they wanted, something you never could know since you never operated with them.

So, with these guys that are blamed as being "clumsy in the OR" is it something all surgeon thinks or is it enough someone is unhappy with the assisting from a med student?
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I am guessing that you are an ESL. In US academic centers, there is not a ton of one-on-one operative experience with the attendings. This can be different in the community.

In my environment, which is an academic medical center, I rarely witness medical students suturing, as I usually leave the room prior to that happening. The residents are usually the teachers and the critics. Since starting practice, I've never discussed a student's technical skills with another attending.
 
southernIM said:
We talk very very little about medical students' technical skills.

I frequently participate in our structured skills teaching sessions for medical students (knot tying, basic suture techniques, lap skills, etc) as well as the usual OR interactions. I would say I come across perhaps one student per year who is such an outlier (either good or bad) as to catch my attention.

When we talk about students, it is 99.9% about their knowledge base, clinical judgment, and attitude/work ethic.
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+1

Although we talk **** about the intern's technical abilities all the time 😉
 
Throughout my residency, fellowship training and now in practice, I do not ever recall talking about a medical student's skills, except with the student themselves as part of a formal evaluation.

Medical student are not expected to have any "skills". I cannot even imagine how bad you would have to be for us to bother discussing it amongst ourselves or with staff.

I did have one syncope and go down this week and I only mentioned that to staff to praise her for letting me know that she needed to let go of the retractors *first*.
 
For another perspective, in neuro the residents and attendings do tend to discuss the students knowledge base and technical ability. We use interrupted pop-off sutures which requires a fair amount of hand tying and is a basic skill in which students can show proficiency. Further technical skills are progressed from there e.g. suturing and so on.
 
neusu said:
For another perspective, in neuro the residents and attendings do tend to discuss the students knowledge base and technical ability. We use interrupted pop-off sutures which requires a fair amount of hand tying and is a basic skill in which students can show proficiency. Further technical skills are progressed from there e.g. suturing and so on.
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I think a bit of clarification is needed.

I would venture that all specialties talk about student knowledge base. I would presume that to be routine.

Pop-off interrupted sutures are also widely used in general surgery and plastics (they may be as well in other surgical subs, that I don't know about). Whether students actually get to throw some is highly dependent on the case and the faculty.

Perhaps GS tend to talk about student skill levels less than NSGY because everyone does a GS rotation; students rotating with you may be doing an elective/sub-I/audition rotation where it makes more sense to talk about surgical skill as you may be evaluating them for residency candidacy. If someone were rotating on GS as a sub-I/audition, then discussion of surgical skills is more relevant.
 
Thanks all for your answers. It seems legit to focus on students skills in surgical care rather than the technical abilities. I just felt a bit worried when they were talking bad about some students, and it seems to differ some between surgeons what is good and what is not.

As I wrote, some seem to get pissed for small stuff, for example, when I ligate vessels I always tightens the knot with my index finger, and the other surgeon said this was all wrong and that I should use my thumb which feels really weird. I would be kind of annoyed if he then goes and tells other surgeons I have bad technical abilities/knowledge because of that..

However, even if the surgeon seems pissed when not doing like they want, I guess they are also aware of the fact that students may be differently taught by different surgeons.

And yes, I am an ESL.
 
roinom said:
Thanks all for your answers. It seems legit to focus on students skills in surgical care rather than the technical abilities. I just felt a bit worried when they were talking bad about some students, and it seems to differ some between surgeons what is good and what is not.

As I wrote, some seem to get pissed for small stuff, for example, when I ligate vessels I always tightens the knot with my index finger, and the other surgeon said this was all wrong and that I should use my thumb which feels really weird. I would be kind of annoyed if he then goes and tells other surgeons I have bad technical abilities/knowledge because of that..

However, even if the surgeon seems pissed when not doing like they want, I guess they are also aware of the fact that students may be differently taught by different surgeons.

And yes, I am an ESL.
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If you tightened suture routinely with anything but your index finger when suturing virtually anything, you would get reamed by our CV faculty.
 
mimelim said:
If you tightened suture routinely with anything but your index finger when suturing virtually anything, you would get reamed by our CV faculty.
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Agreed.

I've never seen someone tighten a knot with their thumb - after all, the index or middle finger have much more length and can reach farther. The index finger is also said to have the most control.
 
Seems these days nobody knows how to suture or tie as a medical student. I have zero expectations anymore. I guess nobody takes this rotation seriously other than to get out as early as possible and hit the books for the shelf exam. Back in my day (You can tell I'm getting old) I used to have a packet of ties with me and my entire house was littered with ties. I took some needle drivers and practiced suturing basic things when I'm on call. Some of that is because I was interested and ended up in surgery. Part of that was just be wanting to be good at what I do, you know, like basic pride. But these days people can't even seem to throw a single two handed knot (or even a single handed). I see this in some of the interns and even early second years too. It's sad. Then again my open skills are probably a year or so behind the graduating chiefs from 10 years ago (too much laparoscopy)

The only thing that I expect from medical students these days is to have a basic understanding of surgical problems and their work up. I don't expect them to know anything about suturing, tying, preop work up, how to write notes, what to look for in postop check, how to write progress notes, how to work up a consult, or even how to examine a belly and ask about past surgeries. I just want them to smile and be pleasant as long as they don't expect that to translate to an A or Honors, just for having a good personality. I really don't understand it. They get more and more "early clinical exposure" during medical school, they do more skills labs like suturing and even laparoscopy and bowel anastomosis, yet most of them are light years behind the students from less than a decade ago in every metric other than perhaps theoretical knowledge base (i.e. shelf materials).
 
Only time I saw a faculty tighten with their thumb was on CV. I occasionally do it when I need a little more umph in a narrow cavity.

mimelim said:
If you tightened suture routinely with anything but your index finger when suturing virtually anything, you would get reamed by our CV faculty.
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This particular attending did it fairly often. He would also frequently break the AORN rules that didn't make sense and get all the nurses worked up. He had a very practical way about things that made him fun to work with.

mimelim said:
Occasionally, I don't think anyone reasonable cares about. It is the always doing it that is considered a "bad habit" in the eyes of some.
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filter07 said:
Seems these days nobody knows how to suture or tie as a medical student. I have zero expectations anymore. I guess nobody takes this rotation seriously other than to get out as early as possible and hit the books for the shelf exam. Back in my day (You can tell I'm getting old) I used to have a packet of ties with me and my entire house was littered with ties. I took some needle drivers and practiced suturing basic things when I'm on call. Some of that is because I was interested and ended up in surgery. Part of that was just be wanting to be good at what I do, you know, like basic pride. But these days people can't even seem to throw a single two handed knot (or even a single handed). I see this in some of the interns and even early second years too. It's sad. Then again my open skills are probably a year or so behind the graduating chiefs from 10 years ago (too much laparoscopy)

The only thing that I expect from medical students these days is to have a basic understanding of surgical problems and their work up. I don't expect them to know anything about suturing, tying, preop work up, how to write notes, what to look for in postop check, how to write progress notes, how to work up a consult, or even how to examine a belly and ask about past surgeries. I just want them to smile and be pleasant as long as they don't expect that to translate to an A or Honors, just for having a good personality. I really don't understand it. They get more and more "early clinical exposure" during medical school, they do more skills labs like suturing and even laparoscopy and bowel anastomosis, yet most of them are light years behind the students from less than a decade ago in every metric other than perhaps theoretical knowledge base (i.e. shelf materials).
Click to expand...

Maybe because that is all we are allowed to do as medical students. Let's go with "I don't expect them to know anything about preop work up, how to write notes, what to look for in a postop check, how to write progress notes, how to work up a consult, or how to examine a belly and ask about past surgeries" - I can tell you right now that as more and more medical schools transition to EMR, very few programs allow students to write notes that actually get read. The only place where my notes were actually read by the intern (and therefore useful to him, and to me for feedback purposes) is the VA. At my institution, EPIC auto-deletes my notes, and gives me totally different templates than what residents use. I cannot put in orders, even with a cosign and trying to do it anyway just creates more work for residents. Maybe when/where you went to medical school, you were allowed to play a much more hands-on role. Most of us nowadays aren't as "involved" with patient care because we aren't allowed to be. Sure, I can go see a consult patient and examine them, but don't expect me to write the note on them, because my EMR access won't let me do it, and even if it does, you can't use the note, because Medicare won't approve of any notes that are written by a medical student and then cosigned by a resident. So in the end, all I am doing is asking the resident to take additional time out of his schedule to look at the stupid note that I wrote. Again, the only exeption in my experience was the VA. Believe it or not, I would love to write notes, see consults and put notes/orders in for them and would get very proficient at it with some basic guidance, but the infrastructure is no longer there. People like you who then complain that medical students today suck, make the problem worse by irritating those of us who really would love to do more but feel less and less motivated by how little we actually get to do. At the end of the day, it is more constructive for me to go home and read case files than sit around watching the resident write notes, which is what ends up happening. Blame the red-tape, disdain that many patients have for letting medical students do stuff, and the fear on the part of residents of letting students do stuff. Blame all that oversight, not the students who are thrown into a confusing mix of being told not to do anything, but being expected to know how to do a job they have never been allowed to do. You aren't helping.
 
Did you share any of this with your course director because most of the issues that you raise are fixable? For example, we used EPIC in training and our implementation did not delete student notes. Residents just had to addend them with their own H&Ps for billing reasons. In fact sometimes I found the student notes more helpful than the resident notes.

Food said:
Maybe because that is all we are allowed to do as medical students. Let's go with "I don't expect them to know anything about preop work up, how to write notes, what to look for in a postop check, how to write progress notes, how to work up a consult, or how to examine a belly and ask about past surgeries" - I can tell you right now that as more and more medical schools transition to EMR, very few programs allow students to write notes that actually get read. The only place where my notes were actually read by the intern (and therefore useful to him, and to me for feedback purposes) is the VA. At my institution, EPIC auto-deletes my notes, and gives me totally different templates than what residents use. I cannot put in orders, even with a cosign and trying to do it anyway just creates more work for residents. Maybe when/where you went to medical school, you were allowed to play a much more hands-on role. Most of us nowadays aren't as "involved" with patient care because we aren't allowed to be. Sure, I can go see a consult patient and examine them, but don't expect me to write the note on them, because my EMR access won't let me do it, and even if it does, you can't use the note, because Medicare won't approve of any notes that are written by a medical student and then cosigned by a resident. So in the end, all I am doing is asking the resident to take additional time out of his schedule to look at the stupid note that I wrote. Again, the only exeption in my experience was the VA. Believe it or not, I would love to write notes, see consults and put notes/orders in for them and would get very proficient at it with some basic guidance, but the infrastructure is no longer there. People like you who then complain that medical students today suck, make the problem worse by irritating those of us who really would love to do more but feel less and less motivated by how little we actually get to do. At the end of the day, it is more constructive for me to go home and read case files than sit around watching the resident write notes, which is what ends up happening. Blame the red-tape, disdain that many patients have for letting medical students do stuff, and the fear on the part of residents of letting students do stuff. Blame all that oversight, not the students who are thrown into a confusing mix of being told not to do anything, but being expected to know how to do a job they have never been allowed to do. You aren't helping.
Click to expand...
 
Food said:
Maybe because that is all we are allowed to do as medical students. Let's go with "I don't expect them to know anything about preop work up, how to write notes, what to look for in a postop check, how to write progress notes, how to work up a consult, or how to examine a belly and ask about past surgeries" - I can tell you right now that as more and more medical schools transition to EMR, very few programs allow students to write notes that actually get read. The only place where my notes were actually read by the intern (and therefore useful to him, and to me for feedback purposes) is the VA. At my institution, EPIC auto-deletes my notes, and gives me totally different templates than what residents use. I cannot put in orders, even with a cosign and trying to do it anyway just creates more work for residents. Maybe when/where you went to medical school, you were allowed to play a much more hands-on role. Most of us nowadays aren't as "involved" with patient care because we aren't allowed to be. Sure, I can go see a consult patient and examine them, but don't expect me to write the note on them, because my EMR access won't let me do it, and even if it does, you can't use the note, because Medicare won't approve of any notes that are written by a medical student and then cosigned by a resident. So in the end, all I am doing is asking the resident to take additional time out of his schedule to look at the stupid note that I wrote. Again, the only exeption in my experience was the VA. Believe it or not, I would love to write notes, see consults and put notes/orders in for them and would get very proficient at it with some basic guidance, but the infrastructure is no longer there. People like you who then complain that medical students today suck, make the problem worse by irritating those of us who really would love to do more but feel less and less motivated by how little we actually get to do. At the end of the day, it is more constructive for me to go home and read case files than sit around watching the resident write notes, which is what ends up happening. Blame the red-tape, disdain that many patients have for letting medical students do stuff, and the fear on the part of residents of letting students do stuff. Blame all that oversight, not the students who are thrown into a confusing mix of being told not to do anything, but being expected to know how to do a job they have never been allowed to do. You aren't helping.
Click to expand...

Preach.

EMR is destroying medical education.
 
Here is a simple solution....don't be so tied to the EMR. I ask medical students to hand write notes, h/p, etc. I'll then look them over and make comments. It gives them practice and doesn't really make that much more work for me. In fact, the 'good' medical students will do this anyway, acknowledging the flaw in our system that prevents them from writing in the EMR. Also, I find that students who do use the EMR write terrible notes. They rely too heavily on templates, and then when these students make it to intern year, their notes are worthless, including only auto populated garbage. Stop complaining about 'not being able to write notes in the computer'. You have a hand (presumably), and someone can lend you a pen and paper.
 
balaguru said:
Did you share any of this with your course director because most of the issues that you raise are fixable? For example, we used EPIC in training and our implementation did not delete student notes. Residents just had to addend them with their own H&Ps for billing reasons. In fact sometimes I found the student notes more helpful than the resident notes.
Click to expand...

The student can act as a "scribe," which can be used for documentation by the attending, but the attending is attesting that they did the work while the student wrote things down. Otherwise, it's basically fraud.

Residents cannot use students as scribes in most hospitals, for billing and medicolegal reasons as you mentioned. So, the days are long gone when you can "agree with above" on a student note, EPIC or not.

A separate concept is the "medical student note," which never becomes a part of the permanent medical record, and EPIC deletes it at the end of the encounter. It's basically practice notes, but what I've found is that the residents never read them, or critique them, so education is suffering a little bit.

It is my understanding that residents must create a separate note to be signed by the attending. Otherwise, the attending cannot bill for that care. For postop patients, it probably doesn't matter.

I'd be interested to hear from someone with more experience on the matter.
 
DrNick Riviera said:
Here is a simple solution....don't be so tied to the EMR. I ask medical students to hand write notes, h/p, etc. I'll then look them over and make comments. It gives them practice and doesn't really make that much more work for me. In fact, the 'good' medical students will do this anyway, acknowledging the flaw in our system that prevents them from writing in the EMR. Also, I find that students who do use the EMR write terrible notes. They rely too heavily on templates, and then when these students make it to intern year, their notes are worthless, including only auto populated garbage. Stop complaining about 'not being able to write notes in the computer'. You have a hand (presumably), and someone can lend you a pen and paper.
Click to expand...

The harder part, I've found, is finding a large, consistent set of residents willing to do this extra work.
 
VisionaryTics said:
Preach.

EMR is destroying medical education.
Click to expand...
EMR is being so heavily used because of government reimbursement. Thank the government for that one.

Pretty much anything negative you can think of regarding patient care, medical training, and medical education can be tied to reimbursement or accreditation.
 
SLUser11 said:
The student can act as a "scribe," which can be used for documentation by the attending, but the attending is attesting that they did the work while the student wrote things down. Otherwise, it's basically fraud.

Residents cannot use students as scribes in most hospitals, for billing and medicolegal reasons as you mentioned. So, the days are long gone when you can "agree with above" on a student note, EPIC or not.

A separate concept is the "medical student note," which never becomes a part of the permanent medical record, and EPIC deletes it at the end of the encounter. It's basically practice notes, but what I've found is that the residents never read them, or critique them, so education is suffering a little bit.

It is my understanding that residents must create a separate note to be signed by the attending. Otherwise, the attending cannot bill for that care. For postop patients, it probably doesn't matter.

I'd be interested to hear from someone with more experience on the matter.
Click to expand...

SLUser is correct. Medical student documentation can be used by an attending and cosigned by an attending that includes an attestation that the student worked as a scribe. The student can collect HPI, ROS, PMH/PSH, but the examination and medical decision making must be part of the attending note. Residents cannot cosign a student note. EPIC's solution is actually a very good one -- the student gets to write a note that can be reviewed, but it is not part of the medical record.

While the student misses out of some educational work, they are also protected from scut.

And while you complain that EMR is destroying medical education, in many circumstances it improves my ability as an attending to provide care. In the "bad old days" it was hard to track down the hand-written notes from a patient's in-patient hospitalization!! And God forbid that you need to get information on a patient who was just discharged -- the paper chart was gone to the land of collation and filing. Sure, I spend a lot of time typing, but I appreciate the fact that I can see all of the notes from all of the physicians in my system (and sometimes other systems) very quickly.
 
I find it sad that a simple thing like EPIC is so easily able to destroy medical education in the eyes of medical students. While it is true that there is a greater psychological barrier to doing this work, since it feels like "extra" or "non-productive", I should remind medical students that there is absolutely no restriction on medical students writing notes or coming up with plans for patients. There is more burden on the medical student to be self-motivated. While I readily acknowledge this burden and the psychological barrier it creates, there is nothing preventing a medical student from writing a note and comparing their note to mine. Instead, people will just say "our notes don't count" and never write a pre-op note, post-op note, progress note, or consult note. Hey, how about using the 10 minutes you saved typing a note pre-populated with all the vitals and labs to present in the morning? Maybe then it's not as useless and you may learning something other than how to follow the residents around with your hands in your pockets. Don't mistake laziness for lack of opportunity.
 
+1.

Anybody that thinks paper charts somehow provided better or even equivalent patient care--now I don't say this often--is plain wrong.

maxheadroom said:
SLUser is correct. Medical student documentation can be used by an attending and cosigned by an attending that includes an attestation that the student worked as a scribe. The student can collect HPI, ROS, PMH/PSH, but the examination and medical decision making must be part of the attending note. Residents cannot cosign a student note. EPIC's solution is actually a very good one -- the student gets to write a note that can be reviewed, but it is not part of the medical record.

While the student misses out of some educational work, they are also protected from scut.

And while you complain that EMR is destroying medical education, in many circumstances it improves my ability as an attending to provide care. In the "bad old days" it was hard to track down the hand-written notes from a patient's in-patient hospitalization!! And God forbid that you need to get information on a patient who was just discharged -- the paper chart was gone to the land of collation and filing. Sure, I spend a lot of time typing, but I appreciate the fact that I can see all of the notes from all of the physicians in my system (and sometimes other systems) very quickly.
Click to expand...
 
Food said:
Maybe because that is all we are allowed to do as medical students. Let's go with "I don't expect them to know anything about preop work up, how to write notes, what to look for in a postop check, how to write progress notes, how to work up a consult, or how to examine a belly and ask about past surgeries" - I can tell you right now that as more and more medical schools transition to EMR, very few programs allow students to write notes that actually get read. The only place where my notes were actually read by the intern (and therefore useful to him, and to me for feedback purposes) is the VA. At my institution, EPIC auto-deletes my notes, and gives me totally different templates than what residents use. I cannot put in orders, even with a cosign and trying to do it anyway just creates more work for residents. Maybe when/where you went to medical school, you were allowed to play a much more hands-on role. Most of us nowadays aren't as "involved" with patient care because we aren't allowed to be. Sure, I can go see a consult patient and examine them, but don't expect me to write the note on them, because my EMR access won't let me do it, and even if it does, you can't use the note, because Medicare won't approve of any notes that are written by a medical student and then cosigned by a resident. So in the end, all I am doing is asking the resident to take additional time out of his schedule to look at the stupid note that I wrote. Again, the only exeption in my experience was the VA. Believe it or not, I would love to write notes, see consults and put notes/orders in for them and would get very proficient at it with some basic guidance, but the infrastructure is no longer there. People like you who then complain that medical students today suck, make the problem worse by irritating those of us who really would love to do more but feel less and less motivated by how little we actually get to do. At the end of the day, it is more constructive for me to go home and read case files than sit around watching the resident write notes, which is what ends up happening. Blame the red-tape, disdain that many patients have for letting medical students do stuff, and the fear on the part of residents of letting students do stuff. Blame all that oversight, not the students who are thrown into a confusing mix of being told not to do anything, but being expected to know how to do a job they have never been allowed to do. You aren't helping.
Click to expand...

I print the note out for my residents after deleting patient information from it.... Residents will review it and come back to me with critiques. I type it in EPIC but don't use a template or smart phrases. It isn't saved in the record but that doesn't really change the educational value of it.
 
filter07 said:
I find it sad that a simple thing like EPIC is so easily able to destroy medical education in the eyes of medical students. While it is true that there is a greater psychological barrier to doing this work, since it feels like "extra" or "non-productive", I should remind medical students that there is absolutely no restriction on medical students writing notes or coming up with plans for patients. There is more burden on the medical student to be self-motivated. While I readily acknowledge this burden and the psychological barrier it creates, there is nothing preventing a medical student from writing a note and comparing their note to mine. Instead, people will just say "our notes don't count" and never write a pre-op note, post-op note, progress note, or consult note. Hey, how about using the 10 minutes you saved typing a note pre-populated with all the vitals and labs to present in the morning? Maybe then it's not as useless and you may learning something other than how to follow the residents around with your hands in your pockets. Don't mistake laziness for lack of opportunity.
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You equate medical education utility with reading off a set of vitals and labs to you? Serious?

Cause thats not medicine nor is it even a modern form of education, its a pointless task in obedience which has given birth to the corporate lackey physician culture. The kind of obedient and minds that operate without a granule of medicine (pathophysiology of disease and its management based on scientific research) in their minds.

This is across all specialties for the self righteous and indignant attendings who need to he propped up, while they brag about 120 hr work weeks that were not half as difficult as todays 80 hr week. How long did your patients stay for? Oh yea 30 days, while todays census turns over every 3 days so a resident ends up working on 10 times the patients you saw in the same timeframe. But now with the "importance" of paperwork, which distracts and wastes 50% of residents time during their education.

Time where they could actually read into a patients case and build on their medical knowledge rather than dedicate a CME equivalent a year like you gas bags, leaving their medical knowledge usually behind a rising MS4 in this day and age.

"Uh but doesn't your PPI prophylaxis use (besides being too widespread) have negative consequences?"

"There are none"

But.."A person's basal acid production is an immune barrier to bacteria such as C diff from reaching an infective level leading to gastritis. And Uh calcium needs to be ionized by protons in the stomach in order to be properly absorbed"

Or maybe that fem pop procedure clearly lacked any chance of improving this 94 yo with CHFs function worth the increased morbidity she later experienced.

Or 35% false positive appendix removals, or your lack of concern for manipulating this patients gut (why don't I dry it with towel real quick for god only knows what reason) during the procedure contributed to his adhesions and later obstruction, or that hernia mesh isn't as benign as you may think down the road, or that you lack insight into this patient's other morbidities that would have made you otherwise defer this elective procedure, or ERCP should be more judiciously used in your institution consider the number of hemmorhagic pancreatitis cases, or maybe you should do a little more systemic peer review than grilling someone about 1 case while providing zero constructive comments aimed at addressing this residents poor decision at this time because in the time they spend dictating your BS for insurance they could have become an atari on the subject with new contributions to the area

Oral presentations for the sake of them I think are the last exercise to improve the medical knowledge base of physicians that I can think of. Oh wait its great because you don't have to do anything or prepare and can avoid questions seeking legit knowledge or that exercise the critical thinking capability that your generation of showman physicians with vodoo powers cared to question or improve on.

I'm generalizing for effect here, i know its just some gas bags. But it frightens me learning of how medicine ends up being practiced in this corporate culture of obedience filled with mind numbing paperwork. Paperwork and forms that no one looks at again unless necessary history taking which for future chart review of another admission, which doesn't necessitate daily progress notes for days without new developments or nominal ones.

Language is a tool for effective communication between humans and not just for institutional guidelines or insurance or liability, so its about as natural a thing for a student to feel idiotic presenting crap you have in front of you. And clinical education is a terribly inefficient way to learn in todays environment with residents/attendings who do not have the time for actual instruction cause of all the BS paperwork. They should be able to see patients on their own and at their own pace at this stage without being pulled away for indoctrination with paperwork.

They should then be able to talk with a resident/physician about the case, but when they don't have time they should be reading about the patient rather than having to follow residents around as they do paperwork with hands in their pockets because they are required to be there. And have to put on a front of excitement to be a concierge to residents/attendings or to pretend they are learning from watching people do paperwork or repeat structured presentations without insight back and forth.

Testing a person is not equivalent to teaching a person and get over your feudal view of medical education as physicians are supposed to be subsidizing the cost of it with clinical activities as they used to (and by LCME standards) before you let the vultures suck profit out of medicine and inflate our healthcare costs cause its so great when you gamble and win at stocks
 
But I agree computer charts are superior in their ability to provide patient background and lighten the burden of paperwork through templates. They are still burdensome records that do not efficiently transmit a patients course and could be used as a source of self peer review to reflect on cases if the current documentation level wasn't so high.

"If you didn't document it, it didn't happen"

uh no, it happened or not as a moment in time and documentation does not make it exist or not exist.

The end goal of everything should be how to improve patient outcomes with transmission and records of pertient and basic info for future encounters. It should also be an opportunity to self assess practice habits and monitor uncorrupted research into each case.

You know using your mind to think, elevate your skills and your professions. Not become more productive and efficient at coding and charting for the sake of charting for some person or institution that does not have the obligation to patient that you have. Don't buy in so easily to the assembly line of pathology that medicine has become so accepting of. You never have to look hard for cases daily where a patients care could have been more effectively managed or not caused morbidity because the god given intelligence of the physician has been filtered out.

This isnt about being "good" or "bad" but about improving in every practice area, which is an infinte journey we are all connected to. There is no definitive treatment as pathology can't be treated in isolation to the ongoing and resctive physiological mechanisms of the body, which will allows be better than a doc at curing itself.

Why all the IV fluids, oh yea to support billing for inpatient admissions despite infection, thrombi formation, and mainlining fluids is inferior to the guts ability to regulate its water and electrolyte status as an example of medicine inferior to the body's method. Oh what do you know edema and pleural effusions! Oh yea the pt laying in bed for 2 days is more likely the source of thrombus than the needle line that invariably causes one! So not even using IV judiciously fails obligation to beneficence in my eyes.

For the OP i have seen several attendings do this to varying degrees and always coming off as 2 year olds. Technical skills for rotating students, especially minute individual "ways of doing this", are less important learning objectives than patient management and bringing together basic and clinical science in real life.

If they rate as objectives, as suctioning or retracting to an attendings liking is an educational objective of surgical techs which is a skill interns should master. And students shouldn't be agitated for not having this innate knowledge they assume everyone has the first time. Ask them about the patients presentation, history, workup, and management options and risks to find out your retraction skills lacking are far less important
 
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ferning said:
"If you didn't document it, it didn't happen"
Click to expand...

I think there's a lot you don't understand about the way surgeons teach and the intent behind some of the examples you cite below. Regardless, I don't think there's any way I can change your mind on this topic so bypass that entirely. I just want to point out that when this quote comes up, it references medico-legal aspects of medicine (in a courtroom, lack of documentation basically means a win for the plaintiff) and the importance of continuity of care (if you don't write it down, no one else who may be caring for the patient will know about it if you are not around to tell them and this can have unpleasant/dire adverse consequences). It is not nit-picking, it is an analogy where you would probably personally respond better to a simile: "if you didn't document it, it is AS IF it didn't happen."
 
ferning said:
You equate medical education utility with reading off a set of vitals and labs to you? Serious?

Blah blah blah.
Click to expand...

Well, that was an unprovoked rant. Go back and re-read Filter07's comment.

"Hey, how about using the 10 minutes you saved (typing a note pre-populated with all the vitals and labs) to present in the morning? He wants students to do oral presentations, not rattle off vitals.

Anyway, you sound quite butt-hurt over the way you've been treated by your residents and attendings. I'm sorry your experience was negative, but you know very little about surgical education on a national level, either where it's been or where it's going.

SDN is a perfectly fine place to live out your fantasies of proving how much smarter and talented you are than your superiors....even if it's in a manic, tangential fashion. However, the flight of ideas approach has me confused to whether you are a genius troll or you just forgot to take your lithium. Either way, I recommend toning it down a little if you want people to read the whole post instead of skimming through the second half out of fatigue...
 
the real damage to med stud education is the trickle down to the damage that has become to resident education. While the days where the attending would be on the golf course and the PGY5 would be taking the PGY3 thru the whipple were clearly bad for the patients, when the PGY5 and PGY3 are doing all the actual case, when the end comes and its clean up time, the med stud gets to really get their hands dirty. Now when the attending is obligated to essentially be in the room the entire time and has to be hand holding the PGY5 through the case, the PGY3 that might or might not be double scrubbed, would be the one finally getting to do something at closing time, and the med student gets to do nothing. Residents who are being yelled at if they go 30 minutes over time no long have time to sit and teach the med students since they have to do more turnovers, etc. etc. etc. And, the larger size med school classes means more med students doing rotations (and the invasion of the caribbean students into hospitals with US students already rotating) means that a team that historically had 2 students now ends up with 4, and thus their are less cases to go around, less residents to go around, etc. etc. etc.

EMR does hurt med stud learning to be a functional intern, no doubt (I try to teach all my AI's and even most of my 3rd year med studs how to write orders, transfer patients, be efficient, but I realize this was much easier prior to my hospital converting to EPIC order entry)... but you can get around it and make it work.
 
ferning said:
You equate medical education utility with reading off a set of vitals and labs to you? Serious?

Cause thats not medicine nor is it even a modern form of education, its a pointless task in obedience which has given birth to the corporate lackey physician culture. The kind of obedient and minds that operate without a granule of medicine (pathophysiology of disease and its management based on scientific research) in their minds.

This is across all specialties for the self righteous and indignant attendings who need to he propped up, while they brag about 120 hr work weeks that were not half as difficult as todays 80 hr week. How long did your patients stay for? Oh yea 30 days, while todays census turns over every 3 days so a resident ends up working on 10 times the patients you saw in the same timeframe. But now with the "importance" of paperwork, which distracts and wastes 50% of residents time during their education.

Time where they could actually read into a patients case and build on their medical knowledge rather than dedicate a CME equivalent a year like you gas bags, leaving their medical knowledge usually behind a rising MS4 in this day and age.

"Uh but doesn't your PPI prophylaxis use (besides being too widespread) have negative consequences?"

"There are none"

But.."A person's basal acid production is an immune barrier to bacteria such as C diff from reaching an infective level leading to gastritis. And Uh calcium needs to be ionized by protons in the stomach in order to be properly absorbed"

Or maybe that fem pop procedure clearly lacked any chance of improving this 94 yo with CHFs function worth the increased morbidity she later experienced.

Or 35% false positive appendix removals, or your lack of concern for manipulating this patients gut (why don't I dry it with towel real quick for god only knows what reason) during the procedure contributed to his adhesions and later obstruction, or that hernia mesh isn't as benign as you may think down the road, or that you lack insight into this patient's other morbidities that would have made you otherwise defer this elective procedure, or ERCP should be more judiciously used in your institution consider the number of hemmorhagic pancreatitis cases, or maybe you should do a little more systemic peer review than grilling someone about 1 case while providing zero constructive comments aimed at addressing this residents poor decision at this time because in the time they spend dictating your BS for insurance they could have become an atari on the subject with new contributions to the area

Oral presentations for the sake of them I think are the last exercise to improve the medical knowledge base of physicians that I can think of. Oh wait its great because you don't have to do anything or prepare and can avoid questions seeking legit knowledge or that exercise the critical thinking capability that your generation of showman physicians with vodoo powers cared to question or improve on.

I'm generalizing for effect here, i know its just some gas bags. But it frightens me learning of how medicine ends up being practiced in this corporate culture of obedience filled with mind numbing paperwork. Paperwork and forms that no one looks at again unless necessary history taking which for future chart review of another admission, which doesn't necessitate daily progress notes for days without new developments or nominal ones.

Language is a tool for effective communication between humans and not just for institutional guidelines or insurance or liability, so its about as natural a thing for a student to feel idiotic presenting crap you have in front of you. And clinical education is a terribly inefficient way to learn in todays environment with residents/attendings who do not have the time for actual instruction cause of all the BS paperwork. They should be able to see patients on their own and at their own pace at this stage without being pulled away for indoctrination with paperwork.

They should then be able to talk with a resident/physician about the case, but when they don't have time they should be reading about the patient rather than having to follow residents around as they do paperwork with hands in their pockets because they are required to be there. And have to put on a front of excitement to be a concierge to residents/attendings or to pretend they are learning from watching people do paperwork or repeat structured presentations without insight back and forth.

Testing a person is not equivalent to teaching a person and get over your feudal view of medical education as physicians are supposed to be subsidizing the cost of it with clinical activities as they used to (and by LCME standards) before you let the vultures suck profit out of medicine and inflate our healthcare costs cause its so great when you gamble and win at stocks
Click to expand...

:smack:

you again...

35% false positive appy rate hasn't ever been acceptable, even in the days before CT scans existed, it was still only about a 15% rate...

Your little rant about C. diff in the stomach is cute if not entirely laughable, and I'm not even sure what you are referring to as PPI prophylaxis... what backworld country hospital are you a Caribbean student at?

I dunno, I'm at 2 major centers doing vascular and I can't remember the last 90 year old either of them operated on... the closest was an 80 year old who walked 5 miles each day but had an 8.5cm AAA that he got an EVAR for...

But keep on flogging that chicken... maybe one of these days you will be humbled... internship (if you get one, that is), might be a humbling experience...
 
SLUser11 said:
The student can act as a "scribe," which can be used for documentation by the attending, but the attending is attesting that they did the work while the student wrote things down. Otherwise, it's basically fraud.

Residents cannot use students as scribes in most hospitals, for billing and medicolegal reasons as you mentioned. So, the days are long gone when you can "agree with above" on a student note, EPIC or not.

A separate concept is the "medical student note," which never becomes a part of the permanent medical record, and EPIC deletes it at the end of the encounter. It's basically practice notes, but what I've found is that the residents never read them, or critique them, so education is suffering a little bit.

It is my understanding that residents must create a separate note to be signed by the attending. Otherwise, the attending cannot bill for that care. For postop patients, it probably doesn't matter.

I'd be interested to hear from someone with more experience on the matter.
Click to expand...

Our workaround for the issue has been to have the student write the note, then the resident copy pastes it into their own note (presumably fixing it up and hopefully then giving the student feedback, but that may be wishful thinking) for the attending to cosign (if the attending cosigns a student note they are supposed to write a bunch of extra **** so it makes it more appealing for there to be a resident note). The student then deletes their note so that our fraudulent activity (as I presume it is) can't be proven.

The problem is the lazy student who just copy pastes the prior day's note and adds nothing of value, plus the lazy resident who does the same. Then I have fix or sometimes rewrite things and it is less likely that the right person gets the feedback I give on it.
 
dpmd said:
Our workaround for the issue has been to have the student write the note, then the resident copy pastes it into their own note (presumably fixing it up and hopefully then giving the student feedback, but that may be wishful thinking) for the attending to cosign (if the attending cosigns a student note they are supposed to write a bunch of extra **** so it makes it more appealing for there to be a resident note). The student then deletes their note so that our fraudulent activity (as I presume it is) can't be proven.

The problem is the lazy student who just copy pastes the prior day's note and adds nothing of value, plus the lazy resident who does the same. Then I have fix or sometimes rewrite things and it is less likely that the right person gets the feedback I give on it.
Click to expand...

I have no doubt that there are "workarounds" available, but as you mentioned, it's fraud, so not a good long-term plan.

The problem with the way we are handling EMR is that none of these student activities are mandatory, so the practice varies widely based on the time and level of interest among residents and attendings.
 
filter07 said:
Seems these days nobody knows how to suture or tie as a medical student. I have zero expectations anymore. I guess nobody takes this rotation seriously other than to get out as early as possible and hit the books for the shelf exam. Back in my day (You can tell I'm getting old) I used to have a packet of ties with me and my entire house was littered with ties. I took some needle drivers and practiced suturing basic things when I'm on call. Some of that is because I was interested and ended up in surgery. Part of that was just be wanting to be good at what I do, you know, like basic pride. But these days people can't even seem to throw a single two handed knot (or even a single handed). I see this in some of the interns and even early second years too. It's sad. Then again my open skills are probably a year or so behind the graduating chiefs from 10 years ago (too much laparoscopy)

The only thing that I expect from medical students these days is to have a basic understanding of surgical problems and their work up. I don't expect them to know anything about suturing, tying, preop work up, how to write notes, what to look for in postop check, how to write progress notes, how to work up a consult, or even how to examine a belly and ask about past surgeries. I just want them to smile and be pleasant as long as they don't expect that to translate to an A or Honors, just for having a good personality. I really don't understand it. They get more and more "early clinical exposure" during medical school, they do more skills labs like suturing and even laparoscopy and bowel anastomosis, yet most of them are light years behind the students from less than a decade ago in every metric other than perhaps theoretical knowledge base (i.e. shelf materials).
Click to expand...

That's bull****!

I can't count the number of times I've begged and pleaded to be allowed to do even simple things like helping close up the patient. Guess who always did it though? The intern. Or the attending because they wanted to be done quickly. ****, they wouldn't even let me place IVs. During my surgery rotation, I had to go the ED and ask the ED attendings and nurses to allow me to place IVs on patients. Seriously, wtf?! The biggest barrier to learning more procedural stuff during my surgery rotation were the residents and attendings themselves -- the interns needed the experience and they preferentially (as it should be) got to do stuff vs the med student..

Don't get me wrong. I loved my residents. They spent a lot of time teaching me about working up and managing surgical patients, they gave me lots of feedback on my notes and presentations, so I got a lot out of my rotation. Wrote progress notes, pre-op and post-op notes, and consult notes on a daily basis and got good feedback on them -- and my notes were actually used (with addenda)! I was very proactive, seeking out placing NG tubes, Foleys, etc. While I got to do those things, it seemed like no one was willing to teach me more about suturing and tying knots on an actual patient. In my 2-month rotation, I got to suture-close a patient once. On my second-to-last day on service. To be fair though, a good number of my gen surg cases were staple-closed and I did get to do that a lot. But we really did miss out on a lot of procedural stuff that med students probably did even a few years ago.

It's just frustrating to ask around to do as much as possible, get denied, and then have people like you condescendingly talk about how far behind we are compared to students back in the day and automatically assume that we were trying to get out as quickly as possible instead of trying to learn. That's complete bull**** and it's a completely unfair assessment. We were there from 4:30am to 6pm everyday. 30-hour call approxiamtely q7, where we got less sleep than the interns did because we would do all the random post-op checks throughout the night and just forward the notes to the intern, who would co-sign them in the morning. Seriously, the most sleep I got on one of my call nights was 1.5 hours of interrupted sleep. Did not complain once. Everything about medical education is screwed up nowadays. The interns have less exposure than they did previously. So, now, we have M3s, M4s, and interns competing to get procedural experience. All of that rolls downhill -- as students keep graduating with less procedural experience, more M4s and M3s won't get that experience during med school because the interns are playing catch-up. If you want to blame something, blame the system that's currently in place instead of assuming we're being lazy these days.

/rant

Sorry, got sick of hearing stuff like this and just needed to vent. It sucks being allowed to do less and less these days and then hearing residents and attendings complain about how little we know or that we have less experience only because we're lazy and avoiding learning. Often, it's not our fault! The hospital's stupid policy is what prevents us from getting more hands-on experience. They just flat-out say they can't let med students do that -- that's why I couldn't place any IVs on patients getting surgery and had to resort to going down to the ED during down time to get practice.
 
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thedrjojo said:
the real damage to med stud education is the trickle down to the damage that has become to resident education. While the days where the attending would be on the golf course and the PGY5 would be taking the PGY3 thru the whipple were clearly bad for the patients, when the PGY5 and PGY3 are doing all the actual case, when the end comes and its clean up time, the med stud gets to really get their hands dirty. Now when the attending is obligated to essentially be in the room the entire time and has to be hand holding the PGY5 through the case, the PGY3 that might or might not be double scrubbed, would be the one finally getting to do something at closing time, and the med student gets to do nothing. Residents who are being yelled at if they go 30 minutes over time no long have time to sit and teach the med students since they have to do more turnovers, etc. etc. etc. And, the larger size med school classes means more med students doing rotations (and the invasion of the caribbean students into hospitals with US students already rotating) means that a team that historically had 2 students now ends up with 4, and thus their are less cases to go around, less residents to go around, etc. etc. etc.

EMR does hurt med stud learning to be a functional intern, no doubt (I try to teach all my AI's and even most of my 3rd year med studs how to write orders, transfer patients, be efficient, but I realize this was much easier prior to my hospital converting to EPIC order entry)... but you can get around it and make it work.
Click to expand...

Exactly! This is what I was trying to convey in my rant. That's why, nearly every time there was an opportunity to suture, it would be the intern doing it. What am I going to do? Demand that I do it instead when they're just trying to get more experience because they missed out on it as med students? I've had interns and residents apologize to me for not letting me close a patient, but it's not their fault -- it's how the system currently is.

On the flip side, I had no issues with the EMR. We wrote our notes, signed them, and forwarded them to our interns to co-sign. They were all in the system and were read by the interns and residents. Like I said in previous post, I did learn a lot during my rotation because my interns and residents were great teachers and spent a lot of time teaching us students how to manage patients. It's the procedural stuff that we missed out on, unfortunately.
 
At my medical school there was a surgery student interest group that did some hands on activities during the first two years of school, so I didn't need a resident to take the time to show me and I had already had a lot of time to practice before starting a surgery rotation. There needs to be more stuff like that, because it just isn't possible to individually show each of the 24 students (keep in mind we only have 10 total surgical residents and 5 general surgery faculty, one of whom is the dept chair and one of whom is the program director) how to tie and suture and give them an opportunity to practice in the 2 months they spend with us (at least not with everything else that has to get done in a day).
 
dpmd said:
At my medical school there was a surgery student interest group that did some hands on activities during the first two years of school, so I didn't need a resident to take the time to show me and I had already had a lot of time to practice before starting a surgery rotation. There needs to be more stuff like that, because it just isn't possible to individually show each of the 24 students (keep in mind we only have 10 total surgical residents and 5 general surgery faculty, one of whom is the dept chair and one of whom is the program director) how to tie and suture and give them an opportunity to practice in the 2 months they spend with us (at least not with everything else that has to get done in a day).
Click to expand...

We had stuff like this too. I practiced a lot on pig's feet and I got one of those free Ethicon kits to practice tying knots at home. It's just we didn't get a chance to show our skills on actual patients because someone higher up on the chain than us needed the practice. Even during the rotation, my senior resident, during the time I was on gen surg, spent some time with us teaching us how to tie knots. Same thing though, we didn't get a chance to do them on patients because the interns and juniors did them. My classmates at other sites had similar experiences, so my site wasn't an anomaly. My philosophy was to always ask to do stuff because the worst they can say is "no." And I was told "no" (or the popular variant "maybe next time") a lot more than I expected, unfortunately.
 
krafty934 said:
We had stuff like this too. I practiced a lot on pig's feet and I got one of those free Ethicon kits to practice tying knots at home. It's just we didn't get a chance to show our skills on actual patients because someone higher up on the chain than us needed the practice. Even during the rotation, my senior resident, during the time I was on gen surg, spent some time with us teaching us how to tie knots. Same thing though, we didn't get a chance to do them on patients because the interns and juniors did them. My classmates at other sites had similar experiences, so my site wasn't an anomaly. My philosophy was to always ask to do stuff because the worst they can say is "no." And I was told "no" (or the popular variant "maybe next time") a lot more than I expected, unfortunately.
Click to expand...

Ah, but if every school had something like that, then the interns and juniors wouldn't be needing so much practice.
 
dpmd said:
Ah, but if every school had something like that, then the interns and juniors wouldn't be needing so much practice.
Click to expand...

I think there's a reluctance to make technical skill something that's evaluated in medical school. And if it's not evaluated then it's not going to be taught with any sort of rigor. I know I got an A in surgery without ever demonstrating an ability to do anything more skilled than removing sutures or stapling the skin.
 
krafty934 said:
We had stuff like this too. I practiced a lot on pig's feet and I got one of those free Ethicon kits to practice tying knots at home. It's just we didn't get a chance to show our skills on actual patients because someone higher up on the chain than us needed the practice. Even during the rotation, my senior resident, during the time I was on gen surg, spent some time with us teaching us how to tie knots. Same thing though, we didn't get a chance to do them on patients because the interns and juniors did them. My classmates at other sites had similar experiences, so my site wasn't an anomaly. My philosophy was to always ask to do stuff because the worst they can say is "no." And I was told "no" (or the popular variant "maybe next time") a lot more than I expected, unfortunately.
Click to expand...
did they let other students do more than you?

I need a lot of practice, but I'll routinely let a student get their first chance at trying to suture or whatever. Teaching also helps you solidify your skills, as you're teaching proper technique and expressing the mindset behind why they need to do things the way they're done.

as with many other things in medicine, sometimes it's a crapshoot.
 
armybound said:
did they let other students do more than you?

I need a lot of practice, but I'll routinely let a student get their first chance at trying to suture or whatever. Teaching also helps you solidify your skills, as you're teaching proper technique and expressing the mindset behind why they need to do things the way they're done.

as with many other things in medicine, sometimes it's a crapshoot.
Click to expand...

No. Plus, I received excellent evals and one of the PGY-5's and a PGY-4 I worked closely with spent a good amount of time trying to convince me to go into general surgery. So, it's not something to do with me. Other classmates at other sites also noted a pretty similar experience, so it wasn't isolated to my site either.
 
I did very little in my M4 SICU rotation. Placed one a-line, attempted to float a couple Swans. That's it. No central lines, no chest tubes.

Fast forward a decade, and during residency most med students that rotated on SICU with me (and took call) would log anywhere from 8-12 subclavian CVLs, a bunch of a-lines and a couple chest tubes each month. In fellowship, we don't get many med students, but when we do I try to go through the basics of vents and cardiac drips. And chest tubes. And OR stuff.
 
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