Is med student (relative) autonomy at the lowest ever?

[deleted645092]

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So the issue with procedures is that

1) The first few times someone does a procedure their error rate is very high
and
2) Each kind of procedure is only done by a certain kinds of physicians.

This is a situation where the ethical thing is to wait until you're a resident, and we know that you're actually going to need the procedure that we're teaching. It doesn't make any sense to expose a patient to the risk of your untrained suturing/chest tube/IV/appendectomy if there is still a chance that you will end up a psychiatrist.


There's no reason to be embarrassed. Attendings know what medical education is. They will teach you all the procedures you need to know during intern year.

Sorry I didn’t mean to make it sound like I should be putting in chest tubes or anything necessarily invasive like that. Moreso the basic things like shots/ injections, wound dressings, even strep swabs. I haven’t even gotten the chance to do a pelvic exam outside of my SP during 2nd year, I’ve actually been asked to leave anytime there is a female exam occurring. Things that you would probably expect a 4th year medical student or intern to be able to do solo on their first day, even if it isn’t perfect.

 

[MedicineZ0Z]

Sorry I didn’t mean to make it sound like I should be putting in chest tubes or anything necessarily invasive like that. Moreso the basic things like shots/ injections, wound dressings, even strep swabs. I haven’t even gotten the chance to do a pelvic exam outside of my SP during 2nd year, I’ve actually been asked to leave anytime there is a female exam occurring. Things that you would probably expect a 4th year medical student or intern to be able to do solo on their first day, even if it isn’t perfect.

That's honestly ridiculous. You got asked to leave by the doctor even without them asking the patient?

 

[el_duderino]

If students aren't saving you time, you're done it wrong (100% serious).

Yeah, come back once you graduate and let us know how you're doing it.

 

[MedicineZ0Z]

Yeah, come back once you graduate and let us know how you're doing it.

Maybe it's the places I've rotated at (where i still expected more) but students did every single H&P/progress note and the resident would do a (usually) brief edit (sometimes no edit). I won't expand more, but that alone saves time. Especially when each student is doing 4 progress notes day and a couple to few h&Ps.

 

[WedgeDawg]

I feel like this seems to vary heavily by school and even by intra-school rotational site.

In my (totally unexperienced) opinion, 3rd years should be what sets you up at minimum to do the following:

1. Solidify your history and physical taking skills that you learned during M2 and learning more specialized exam maneuvers
2. Learn how to do basic medicine work i.e. preround on your patients focusing on what's important, do an H&P for a new admission, present a patient adjusting for audience (full admissions presentation vs soap style presentation), come up with an assessment, and learn how to create a basic plan for further diagnosis and management
3. Learn how to work as part of a team (i.e. do what needs to be done, regardless of what benefit you think you may or may not be personally getting out of it)
4. Become comfortable interacting with patients
5. Learn how to scrub in and at the very least learn how to cut sutures and tie knots

After that, it comes down more into what you're interested in learning, what you're planning on specializing in, what opportunities you got during your rotations, etc. This means that most 4th years will probably know how to draw blood and place EKG leads, but that students will have varying exposure to doing a-sticks, placing IVs, intubating in the OR, placing NG tubes, doing LPs, suturing lacs, doing more stuff in the OR (basically up to whatever the resident/fellow is comfortable letting you do), putting in a-lines, putting in central lines, using ultrasound for any number of things, paracentesis, managing vent settings, I&Ds, etc (those are the things off the top of my head based on things I know students irl have done).

Again, totally depends on what you want to learn, what rotations you're on, and being in the right place at the right time. I've placed a billion NG tubes but I've never done an a-line or placed an IV. I'm sure there are students who've done a couple central lines that have never intubated or done an LP.

I don't think it's a good idea to have new 3rd years (or even new 4th years or really anyone at the beginning of a given rotation) go see new ED consults of unknown acuity, but I think it's something that you should be able to do for people who aren't actively dying closer to the end of 4th year / your rotation.

What the responses here really tell me though is that this is highly variable and depends on when and where you're doing your rotation and how amenable your supervising residents/fellows/attendings are to letting you do things.

 

[Mass Effect]

No one is showing up to 3rd year with practical knowledge. But you should gain it over the course of a rotation and be able to put in orders to manage bread and butter cases by the end. You learn by doing, not by saying you would do so and so.

So much no to this. You want an MS 3 to learn to manage bread and butter cases by the end of a one month rotation? Maybe. Until you don't recognize a complicated variant of what you think is a "bread and butter" case. There's a reason you're still a student. It's because you haven't learned how to do these things and you don't know what you don't know.

Are medical students even allowed to put in actual orders? This may vary state by state, but on my subinternship, I could only place preliminary orders in the EMR that had to be signed by my intern/resident/attending before they actually were acknowledged.

No, legally, med students are not allowed to put in orders.

So there are 2 issues, notes and orders
Orders became an issue with the advent of electronic health records. Students have never, legally, been able to order anything. They're not licensed. However, in the days of paper orders, they could still effectively write out the entire order, and the residents would just scribble their signatures on the pile of orders the student wrote (often after the order was implemented, which was technically illegal but no one seemed to mind). With EMRs, there is no hiding who wrote the order, so the licensed physicians just need to put in the orders themselves. If this is ever going to improve we would need to lobby states to create true training licenses for students. That would be a great idea, but to the best of my knowledge no one is working on it right now.

I don't think students should be allowed to put in orders. Sorry not sorry. There are some pretty awful MS 3s out there who don't even know what's going on with a patient until it's spelled out for them. That's fine and all, until you start letting them actually put in orders.

 

[Lexdiamondz]

Maybe it's the places I've rotated at (where i still expected more) but students did every single H&P/progress note and the resident would do a (usually) brief edit (sometimes no edit). I won't expand more, but that alone saves time. Especially when each student is doing 4 progress notes day and a couple to few h&Ps.

The ER is completely different to the floor in that regard. Once on the floor, patients are stable, differentiated and have a much more predictable clinical course, so you can feasibly rely on the student's note and not miss anything acutely deadly. In the ER I need to lay eyes and hands on every single patient because a med student miss is much more likely to be catastrophic - I've caught patients with surgical abdomens, patients with head bleeds, pts with active haematemesis and patients with fourniers that a med student totally missed. Having to do your own h&p after listening to someone elses, talking through a differential, etc adds time to my day.

 

[MedicineZ0Z]

The ER is completely different to the floor in that regard. Once on the floor, patients are stable, differentiated and have a much more predictable clinical course, so you can feasibly rely on the student's note and not miss anything acutely deadly. In the ER I need to lay eyes and hands on every single patient because a med student miss is much more likely to be catastrophic - I've caught patients with surgical abdomens, patients with head bleeds, pts with active haematemesis and patients with fourniers that a med student totally missed. Having to do your own h&p after listening to someone elses, talking through a differential, etc adds time to my day.

You can edit an h&p after a student does it. Of course you should assess the patient yourself but the charting aspect can be minimized when someone else does it.

 

[Perrotfish]

I don't think students should be allowed to put in orders. Sorry not sorry. There are some pretty awful MS 3s out there who don't even know what's going on with a patient until it's spelled out for them. That's fine and all, until you start letting them actually put in orders.

If I was designing the system I would give them a training license at the start of MS4. They could put in real orders on their sub I, and 4th year could be a real bridge to internship.

 

[deleted87051]

Maybe it's the places I've rotated at (where i still expected more) but students did every single H&P/progress note and the resident would do a (usually) brief edit (sometimes no edit). I won't expand more, but that alone saves time. Especially when each student is doing 4 progress notes day and a couple to few h&Ps.

You realize it takes an experienced hospitalist 30 seconds to write a progress note, right?

 

[MedicineZ0Z]

You realize it takes an experienced hospitalist 30 seconds to write a progress note, right?

I didn't realize interns are experienced hospitalists. And this is more so about providing an educational benefit without losing time. If you're paid for teaching, you should be teaching.


Also part of this thread has divided into apologists for poor clinical training. Justifying poor quality rotations with every excuse possible.
Like face it, it's absurd anyone has to pay 50k/year to stand in the corner. And no, you don't learn by just discussing a case. You learn by doing. Writing that note, putting in a order that needs cosigning etc. reinforces retention of the thought process.

And if we're so dead set on wasting money, lets at least not waste so much time. Make useless shadow rotations shorter at least. Cut the hours on rotation down. And make med school 3 years if you're apparently not supposed to learn anything until 4th year.

 

[MD-2022]

Definitely has been the trend the last decade. Think about it, society has changed. There are more regulations and protocols.

 

[MedicineZ0Z]

I feel like this seems to vary heavily by school and even by intra-school rotational site.

In my (totally unexperienced) opinion, 3rd years should be what sets you up at minimum to do the following:

1. Solidify your history and physical taking skills that you learned during M2 and learning more specialized exam maneuvers
2. Learn how to do basic medicine work i.e. preround on your patients focusing on what's important, do an H&P for a new admission, present a patient adjusting for audience (full admissions presentation vs soap style presentation), come up with an assessment, and learn how to create a basic plan for further diagnosis and management
3. Learn how to work as part of a team (i.e. do what needs to be done, regardless of what benefit you think you may or may not be personally getting out of it)
4. Become comfortable interacting with patients
5. Learn how to scrub in and at the very least learn how to cut sutures and tie knots

After that, it comes down more into what you're interested in learning, what you're planning on specializing in, what opportunities you got during your rotations, etc. This means that most 4th years will probably know how to draw blood and place EKG leads, but that students will have varying exposure to doing a-sticks, placing IVs, intubating in the OR, placing NG tubes, doing LPs, suturing lacs, doing more stuff in the OR (basically up to whatever the resident/fellow is comfortable letting you do), putting in a-lines, putting in central lines, using ultrasound for any number of things, paracentesis, managing vent settings, I&Ds, etc (those are the things off the top of my head based on things I know students irl have done).

Again, totally depends on what you want to learn, what rotations you're on, and being in the right place at the right time. I've placed a billion NG tubes but I've never done an a-line or placed an IV. I'm sure there are students who've done a couple central lines that have never intubated or done an LP.

I don't think it's a good idea to have new 3rd years (or even new 4th years or really anyone at the beginning of a given rotation) go see new ED consults of unknown acuity, but I think it's something that you should be able to do for people who aren't actively dying closer to the end of 4th year / your rotation.

What the responses here really tell me though is that this is highly variable and depends on when and where you're doing your rotation and how amenable your supervising residents/fellows/attendings are to letting you do things.

3rd year is when you should come up with an accurate diagnosis and plan and actually display solid competence. There are schools that require competence on things like suturing to your assessment/plan and without it you cannot pass.
History taking will be the way of midlevels/AI in the future. Physical exams are obsolete, but sure. Cutting sutures? Cmon..
The stuff you're describing are what you should learn week 1 of a rotation. From there on you should be learning real skills, not doing nurse/tech work.

 

[Lexdiamondz]

I didn't realize interns are experienced hospitalists. And this is more so about providing an educational benefit without losing time. If you're paid for teaching, you should be teaching.


Also part of this thread has divided into apologists for poor clinical training. Justifying poor quality rotations with every excuse possible.
Like face it, it's absurd anyone has to pay 50k/year to stand in the corner. And no, you don't learn by just discussing a case. You learn by doing. Writing that note, putting in a order that needs cosigning etc. reinforces retention of the thought process.

And if we're so dead set on wasting money, lets at least not waste so much time. Make useless shadow rotations shorter at least. Cut the hours on rotation down. And make med school 3 years if you're apparently not supposed to learn anything until 4th year.

I 100% agree.

With that said, it's important to recognise that (at least in the states) we live in a highly reactionary society that is extremely intolerant of risk, and medical students are a highly heterogenous population of people who are prone to a lot of fxck ups (because they're obv still learning) and require a lot of oversight for the sake of patient safety. When you're a senior resident and you have to have oversight of multiple interns who can put in orders and who will guaranteed be with you in the long run, you are going to naturally invest more in teaching an intern than a medical student. Same for a Sub-i - they're committing to your field, so you have a vested interest in giving them autonomy. For a med student rotating for 4 weeks who may well do something else and is just getting their feet wet, the amount of time and interest you invest doesn't pay off nearly as much, especially when it's adding to your own 90 hour workweek.

No rotation should consist of you standing in the corner looking at your feet. If you aren't doing your own H&Ps, writing notes, and performing minimally invasive procedures (IVs, I&Ds, pelvics, etc) then you're getting ripped off. In a controlled setting like the OR, you should be allowed to be 2nd assist (in a C section you should be 1st assist arguably lol) and intubate. With that said, there are times when student autonomy is inappropriate, and part of being a good student is recognising that.

3rd year is when you should come up with an accurate diagnosis and plan and actually display solid competence. There are schools that require competence on things like suturing to your assessment/plan and without it you cannot pass.
History taking will be the way of midlevels/AI in the future. Physical exams are obsolete, but sure. Cutting sutures? Cmon..
The stuff you're describing are what you should learn week 1 of a rotation. From there on you should be learning real skills, not doing nurse/tech work.

You're showing your naivieté with this comment.

 

[mehc012]

3rd year is when you should come up with an accurate diagnosis and plan and actually display solid competence. There are schools that require competence on things like suturing to your assessment/plan and without it you cannot pass.
History taking will be the way of midlevels/AI in the future. Physical exams are obsolete, but sure. Cutting sutures? Cmon..
The stuff you're describing are what you should learn week 1 of a rotation. From there on you should be learning real skills, not doing nurse/tech work.

This is honestly a terrible attitude, and probably why they stick us with so much time in limited roles.
You. Are. Not. Above. Doing. A. Thorough. History. And. Physical.
These things are not irrelevant/obsolete, and the fact that you think they are is a problem in the first place.

 

[mehc012]

If I was designing the system I would give them a training license at the start of MS4. They could put in real orders on their sub I, and 4th year could be a real bridge to internship.

Honestly, what kills me is that I contributed more to the team and was able to increase efficiency as a premed scribe, with more access to the chart and better feedback on my notes, than I have been for several parts of 3rd year. Doctors give surprisingly thorough feedback when they're required to sign on whatever note you've written (and yet they only kept us around because we saved them time).

If a random college kid with no medical knowledge can learn to whip out a high-quality note in minimal time, and that chart can be taken over by the attending and used for charting/billing, I honestly cannot figure out why medical students are more limited. I'm halfway through 3rd year, and I still think that I learned more in my 2yrs of scribing than I've yet to learn in medical school.

Yes, I understand that the roles are different and the crux of the issue is that the student does their own H&P and the real doctors need to do another, but I feel like there should be ways to use some components from the scribe setup to improve the medical student setup. At least for those situations where students do nothing but shadow, we could at a minimum provide usable documentation.

 

[PathoTurnUp1865]

Thought it's just a DO school thing at first but now seeing that it's quite common in MD schools too. Basically the growing pattern of rotations where you're shadowing and/or standing in the corner in some form.

Based on what attendings say, all ms3s had intern level responsibility in the "old days." And north of the border today in Canada, Ms3s put in orders. You need a quality subI that lets you put in orders and treats you like an actual intern.

The outcome is that you're not learning what you need to until intern year. In reality, those things should have been learnt in ms3 and ms4.

Don’t pull DOs into this lol
Every rotation I’ve had so far I’ve been doing intern work. Granted I’m not at our institutions hospital and have been almost exclusively been only doing community hospitals. However, it’s been great! During surgery I was first assist on almost every surgery, on all the others the doc has had me interview, write notes, perform procedures, etc. etc. I’ve also had quite a bit of time to study on top of it all. I’ve loved being the only student on my rotations. It allows me to get close with the attendings. Which in turn I’ve been able to get a LOR from almost every single one of them.

 

[AMEHigh]

I will also add that I don’t think all rotations should be shadowing all the time, but don’t think that you can’t learn from shadowing.

You can still come up with a differential diagnosis, think about what tests you’d want to order and your treatment plan. As you progress through medicine you’ll figure out that medicine is self-directed learning. No one is holding your hand to tell you how to learn everything.

I’m a family med resident and every once in awhile when I’m on a rotation with a specialist, shadowing does occur. They have busy days. But you know what I do, I ask them questions in between patients, I read up on things on my own, I go back and talk to or examine the patient later, etc.

The ability to put in orders adds very little to your education. One can learn plenty in a variety of ways.

Lastly, residents and attendings are human too and patient care should always come first. I’m super tired this week, so I did tell my med student one morning that I was very tired, so I was trying to be as efficient as possible. I did let her see 2 patients on her own, but the rest she just “shadowed.” That’s just the reality of medicine these days, not everything can and should be catered to med students.

 

[WedgeDawg]

3rd year is when you should come up with an accurate diagnosis and plan and actually display solid competence. There are schools that require competence on things like suturing to your assessment/plan and without it you cannot pass.
History taking will be the way of midlevels/AI in the future. Physical exams are obsolete, but sure. Cutting sutures? Cmon..
The stuff you're describing are what you should learn week 1 of a rotation. From there on you should be learning real skills, not doing nurse/tech work.

Are you a third year yet? Honest question

 

[MedicineZ0Z]

Are you a third year yet? Honest question

4th

 

[ciestar]

Don’t pull DOs into this lol
Every rotation I’ve had so far I’ve been doing intern work. Granted I’m not at our institutions hospital and have been almost exclusively been only doing community hospitals. However, it’s been great! During surgery I was first assist on almost every surgery, on all the others the doc has had me interview, write notes, perform procedures, etc. etc. I’ve also had quite a bit of time to study on top of it all. I’ve loved being the only student on my rotations. It allows me to get close with the attendings. Which in turn I’ve been able to get a LOR from almost every single one of them.

Well, it does happen. Quality rotations are key. I have a friend at a DO school who basically spent the entire FM rotation shadowing in an OP office.

 

[el_duderino]

Maybe it's the places I've rotated at (where i still expected more) but students did every single H&P/progress note and the resident would do a (usually) brief edit (sometimes no edit). I won't expand more, but that alone saves time. Especially when each student is doing 4 progress notes day and a couple to few h&Ps.

And what? They don't teach at all? They don't sit through unnecessarily long student presentations on rounds? They don't observe students doing exams or interviews?

Even if students can write notes, which they can't at most institutions, the presence of students still slows everything down. A lot. If you don't think that's true it's because you haven't seen the team run without them.

 

[VincentAdultman]

If students aren't saving you time, you're done it wrong (100% serious).

I have a feeling you’re somewhat overestimating your contributions to your team (100% serious).

 

[MedicineZ0Z]

And what? They don't teach at all? They don't sit through unnecessarily long student presentations on rounds? They don't observe students doing exams or interviews?

Even if students can write notes, which they can't at most institutions, the presence of students still slows everything down. A lot. If you don't think that's true it's because you haven't seen the team run without them.

Well when a hospital is paid money for having students, tough ****. Deal with it.

I have a feeling you’re somewhat overestimating your contributions to your team (100% serious).

Well a couple dozen 1st assists on surgeries that had no other personnel available would count as significant contribution. But yes, by nature having any sort of true trainee slows things down.

 

[VincentAdultman]

Well a couple dozen 1st assists on surgeries that had no other personnel available would count as significant contribution. But yes, by nature having any sort of true trainee slows things down.

I mean OK, but that’s not really what you said in the post I quoted. And “first assist” can mean a lot of things.

 

[Perrotfish]

And what? They don't teach at all? They don't sit through unnecessarily long student presentations on rounds? They don't observe students doing exams or interviews?

Even if students can write notes, which they can't at most institutions, the presence of students still slows everything down. A lot. If you don't think that's true it's because you haven't seen the team run without them.

At military hospitals, where our students are allowed to write notes, I have found it's not a huge impact to have them vs not having them. The note writing and errand running cancels out the observation time and longer presentations, and the teaching happens for the sake of the residents so it's no extra burden to have the students listen too. Other than students who are on their first weeks of their first inpatient rotation (that can extend the day by hours) it generally doesn't help or hurt. A good student can even make the team run a bit faster.

When I rotated through the local children's hospitals, where students weren't allowed to do anything, the team was way faster when the students weren't around.

 

[mehc012]

Well when a hospital is paid money for having students, tough ****. Deal with it.

Well a couple dozen 1st assists on surgeries that had no other personnel available would count as significant contribution. But yes, by nature having any sort of true trainee slows things down.

Meh. I was 'first assist' in a surgery on first day of M2, and ran the camera for half the case...just me and the attending. I wouldn't say that I contributed meaningfully to the team or the case, other than that the surgeon needed some hands, and I had hands, and she was allowed to ask me to put my hands where she needed them for the case while all of the residents were at didactics.
It was also the coolest thing to happen to me that month, by a LONG shot...I was high on that experience for a day or so 😉

Just because you're present and playing a certain role doesn't by any stretch mean that you're contributing significantly or that you're at an intern level. It's good experience for you, but that's not the same thing.

 

[Angus Avagadro]

Students need to be supervised .. period. Maybe not in the room, but their work must be supervised. My son was routinely asked to leave the room during his OB rotation, but the lady students were allowed to stay. I blame this on the attending for not endorsing his attendance. I'm also aware of a case where a med student , unsupervised, suffocated a patient while performing a procedure. Teaching takes time and patience. Students deserve our supervision and input. So do our patients.

 

[MedicineZ0Z]

Students need to be supervised .. period. Maybe not in the room, but their work must be supervised. My son was routinely asked to leave the room during his OB rotation, but the lady students were allowed to stay. I blame this on the attending for not endorsing his attendance. I'm also aware of a case where a med student , unsupervised, suffocated a patient while performing a procedure. Teaching takes time and patience. Students deserve our supervision and input. So do our patients.

Of course they should be supervised. That's not even arguable. Even if you got the hang of something, supervision helps you improve and not repeat errors.
But there's a universe of difference between supervised work and standing in the corner watching.

Shadowing is something you can do on day 1 of a rotation just to get an idea of the flow of things and learn the EMR.

I will also add that I don’t think all rotations should be shadowing all the time, but don’t think that you can’t learn from shadowing.

You can still come up with a differential diagnosis, think about what tests you’d want to order and your treatment plan. As you progress through medicine you’ll figure out that medicine is self-directed learning. No one is holding your hand to tell you how to learn everything.

I’m a family med resident and every once in awhile when I’m on a rotation with a specialist, shadowing does occur. They have busy days. But you know what I do, I ask them questions in between patients, I read up on things on my own, I go back and talk to or examine the patient later, etc.

The ability to put in orders adds very little to your education. One can learn plenty in a variety of ways.

Lastly, residents and attendings are human too and patient care should always come first. I’m super tired this week, so I did tell my med student one morning that I was very tired, so I was trying to be as efficient as possible. I did let her see 2 patients on her own, but the rest she just “shadowed.” That’s just the reality of medicine these days, not everything can and should be catered to med students.

You can also watch youtube videos and do the same thing. I understand more shadowing on specialty outpatient rotations given the nature of the beast. But generalist rotations and basically anything inpatient should never be shadowing based for any ms3-ms4.

 

[Mass Effect]

The ER is completely different to the floor in that regard. Once on the floor, patients are stable, differentiated and have a much more predictable clinical course, so you can feasibly rely on the student's note and not miss anything acutely deadly. In the ER I need to lay eyes and hands on every single patient because a med student miss is much more likely to be catastrophic - I've caught patients with surgical abdomens, patients with head bleeds, pts with active haematemesis and patients with fourniers that a med student totally missed. Having to do your own h&p after listening to someone elses, talking through a differential, etc adds time to my day.

You must not practice where I am.

3rd year is when you should come up with an accurate diagnosis and plan and actually display solid competence. There are schools that require competence on things like suturing to your assessment/plan and without it you cannot pass.
History taking will be the way of midlevels/AI in the future. Physical exams are obsolete, but sure. Cutting sutures? Cmon..
The stuff you're describing are what you should learn week 1 of a rotation. From there on you should be learning real skills, not doing nurse/tech work.

The above is precisely why you're not allowed to put in orders or contribute more than you are. You don't know what you're doing or what you should be doing. You don't understand the role of a physician versus a nurse versus a tech. You don't appreciate the importance of giving good care. Something tells me that you're doing exactly what you're qualified to do on these rotations.

 

[MedicineZ0Z]

You must not practice where I am.



The above is precisely why you're not allowed to put in orders or contribute more than you are. You don't know what you're doing or what you should be doing. You don't understand the role of a physician versus a nurse versus a tech. You don't appreciate the importance of giving good care. Something tells me that you're doing exactly what you're qualified to do on these rotations.

Do you react this way to midlevels who admit/discharge patients independently and/or see patients privately with 0 supervision after a grand total of 500 hours of shadowing + online courses? No, you probably consider them equivalent to a pgy2, lolz. And give them attending level respect too. But yeah, "good care" .. right???

My response was very clear, that ms3-ms4 should not be focused entirely on H&Ps. It should be aimed at learning diagnosis and management. Once you can come up with a good Ddx with an in-depth understanding of everything on it - your history taking also improves as a result. Otherwise you're sitting there asking every single ROS question because you have no way to direct your questions.

Physical exams are important but how often do they change your management in bread and butter IM cases? Look up the sensitivity of a lot of physical exams and consider how common telemedicine is becoming.

And yeah dude, I don't know what I'm doing lol.. Everything is holier than thou when it's a med student doing it but when a midlevel with a fraction of the knowledge comes along doing the exact same thing - it's entirely okay because.... *crickets*

 

[el_duderino]

Physical exams are important but how often do they change your management in bread and butter IM cases?

All the time. "Physical exams are obsolete" and "History taking will be the way of midlevels/AI in the future." Jesus. Your hubris is off the charts man. The core of medicine is the h&p.

If your PE isn't very useful to you, then you should learn how to actually perform one.

 

[Mass Effect]

Do you react this way to midlevels who admit/discharge patients independently and/or see patients privately with 0 supervision after a grand total of 500 hours of shadowing + online courses? No, you probably consider them equivalent to a pgy2, lolz. And give them attending level respect too. But yeah, "good care" .. right???

Midlevels are trained differently. They are trained to do these things on the job. What they lack is the in-depth physiological background as to why. Med school is designed to give you this training over four years just to make you competent enough to learn the real job in residency. Also, I've seen some amazing midlevels and some horrible ones. It doesn't strengthen your argument that MS 3s with zero ward experience and next to zero EMR experience should be putting in orders.

My response was very clear, that ms3-ms4 should not be focused entirely on H&Ps.

Actually, that wasn't your response. If it had been, I doubt we would be having this discussion as no one things that's the only thing they should be focused on. But the fact remains that a lot of MS3 think they know all because they mastered the book learning when, in fact, they're clueless about actual medicine. I'm happy to teach them, but I would never advocate for them to put in orders. Putting in orders isn't even education. You really want to learn? Ask me to look over your list of differentials and ask you to explain why each etiology is ruled in or out (and actually, I do this without being asked). THAT'S how you learn, not by bringing up an order set just to say you did.

It should be aimed at learning diagnosis and management.

Just because you're learning diagnosis and management doesn't mean you stop practicing your history and physical. Can you really not understand this? An H&P is something you'll do the rest of your career and pushing it off on midlevels while you're an MS3 is not only arrogant, it's downright negligent to the education you claim to want.

Once you can come up with a good Ddx with an in-depth understanding of everything on it

Again with the overinflated sense of what's happening on the wards. I have yet to see an MS3 with a good DDx and an in-depth understanding of "everything" on it. If that was the case, they'd have nothing left to learn. More likely, they have superficial understanding of most common ailments and include textbook zebras now and then in hopes that it's right.

- your history taking also improves as a result. Otherwise you're sitting there asking every single ROS question because you have no way to direct your questions.

Wait, what? You want to know the diagnosis before you take a history? You're doing it backwards. The point is to do a thorough history and then FIGURE OUT the diagnosis. The worst doctors are the ones who claim to know the diagnosis as soon as they see the patient and direct their history only at that. That's how you miss things. That's how you get sued. That's how you develop a rep as a bad doctor.

Physical exams are important but how often do they change your management in bread and butter IM cases? Look up the sensitivity of a lot of physical exams and consider how common telemedicine is becoming.

Pretty damn often. Ordering tests willy nilly without a physical exam to know what you're actually looking for is incompetent. Do you diagnose your patient with a migraine when you haven't looked for papilledema? Do you diagnose your patient with a COPD exacerbation when you haven't listened to their lungs? Do you diagnose your patient with cholecystitis when you haven't palpated the appendix? Do you diagnose your patient with a tension headache when you don't know his blood pressure? Statements like the one above are why we're telling you you have A LOT to learn and your posts on here are quite troubling because you're totally oblivious to how much you have to learn. The best medical students are those who know they have a bunch of scraps in their toolbox and that no skill is actually good enough to discard it.

And yeah dude, I don't know what I'm doing lol.. Everything is holier than thou when it's a med student doing it but when a midlevel with a fraction of the knowledge comes along doing the exact same thing - it's entirely okay because.... *crickets*

Most of the midlevels I've seen know way more than an average MS3, hate to break it to you. They may not know more than a doctor after a year or two of residency, but that's a different story. I maintain, you don't know what you're doing. If you did, you'd acknowledge there's a ton you don't know and the stuff you do is far from superior to anyone clinician on the wards. Also, anyone who discounts a proper H&P is clueless about the practice of medicine.

 

[deleted480308]

No med student should have true autonomy.

Your procedures should be supervised, your h/p’s verified, and while you should learn the process of entering orders they should not be acted on until a physician cosigns

 

[deleted407021]

Well, it does happen. Quality rotations are key. I have a friend at a DO school who basically spent the entire FM rotation shadowing in an OP office.

My FM rotation was 100% with residents who loved to teach, had me see all their patients beforehand and come up with A&P to present to the attending. Did a I&D on my own, sutured some lacs. Was forced to hammer home the guidelines for bread and butter diseases. It was good.

That is to say there’s so much variability. Fingers crossed we at least get good experiences for specialties we’re interested in.

 

[deleted480308]

Well, it does happen. Quality rotations are key. I have a friend at a DO school who basically spent the entire FM rotation shadowing in an OP office.

DO here, saw all patients on my own and documented H/P, responsible for knowing labs/imaging and following up on them if they didn’t happen. Present to attending or resident. Procedures with supervision. Our emr wouldn’t let me put in orders but I definitely was responsible for having a stated plan for orders during presentation

Your friend’s school was sucking but it’s not reproducible to all DO programs at all

 

[ciestar]

DO here, saw all patients on my own and documented H/P, responsible for knowing labs/imaging and following up on them if they didn’t happen. Present to attending or resident. Procedures with supervision. Our emr wouldn’t let me put in orders but I definitely was responsible for having a stated plan for orders during presentation

Your friend’s school was sucking but it’s not reproducible to all DO programs at all

Didn’t say it was. Just saying it happens, both MD and DO.

That said, having residents present is very key I’ve noticed.

 

[3characterslong]

More than I’ve done lol

My other favorite... my school has these requirements for observed h&p’s by students. It is a major struggle to get it completed because when does an attending or upper level have time to stand in the room and watch you ask a patient if they have any allergies?

Just fill it out, make sure you have a few weaknesses, and give it to a resident who has seen you present to sign. Finishing up my third rotation and i've done this 3 times. Well, second rotation was a preceptorship so the attending just signed off without looking.

 

[ciestar]

Just fill it out, make sure you have a few weaknesses, and give it to a resident who has seen you present to sign. Finishing up my third rotation and i've done this 3 times. Well, second rotation was a preceptorship so the attending just signed off without looking.

My first two rotations were exactly the same. I just have to have four signoffs... but, yeah, most say you check off the “history taking” part of the h&p if you include it in your written one

 

[sloop]

The idea that MS3s should be ordering stuff (especially without cosign) is absolutely crazy. Even at a really good place, when I was an intern most of us didn't really know what we were doing half the time for the first month or two and the hawk-like attentiveness of pharmacists during the transition was really important.

 

[Rekt]

The responses in this thread are pathetic and it's the fault of you residents and attendings. If you truly believe third year medical students are that dumb, please don't ever have them again. Tell your coordinators/faculty that you're unable to handle working with them.

 

[MedicineZ0Z]

Midlevels are trained differently. They are trained to do these things on the job. What they lack is the in-depth physiological background as to why. Med school is designed to give you this training over four years just to make you competent enough to learn the real job in residency. Also, I've seen some amazing midlevels and some horrible ones. It doesn't strengthen your argument that MS 3s with zero ward experience and next to zero EMR experience should be putting in orders.

That's the excuse you always hear about midlevels. In practice, they do the exact same stuff, very often with 0 supervision. They also lack knowledge of a wide variety of very basic stuff. You not knowing this puts your whole argument into question.

Actually, that wasn't your response. If it had been, I doubt we would be having this discussion as no one things that's the only thing they should be focused on. But the fact remains that a lot of MS3 think they know all because they mastered the book learning when, in fact, they're clueless about actual medicine. I'm happy to teach them, but I would never advocate for them to put in orders. Putting in orders isn't even education. You really want to learn? Ask me to look over your list of differentials and ask you to explain why each etiology is ruled in or out (and actually, I do this without being asked). THAT'S how you learn, not by bringing up an order set just to say you did.

Sure but saying you don't learn via ordering is silly. The action of writing in an order helps you learn management way more than fart in the air discussion. Last year in ms3, I learned the most on an outpatient rotation where I was writing up (yes paper scripts) orders and tests. In fact, each day on that rotation was way more useful than random weeks I've had doing what you described.
If you want to talk about the neuro aspect of learning and retention, I'd be happy to teach you why the action of writing something in (that counts) is what helps you learn more.

Just because you're learning diagnosis and management doesn't mean you stop practicing your history and physical. Can you really not understand this? An H&P is something you'll do the rest of your career and pushing it off on midlevels while you're an MS3 is not only arrogant, it's downright negligent to the education you claim to want.

No **** dude. A lot of people have verbalized the notion that med students should be focused on h&ps and nothing else. That's what my response is towards.

Again with the overinflated sense of what's happening on the wards. I have yet to see an MS3 with a good DDx and an in-depth understanding of "everything" on it. If that was the case, they'd have nothing left to learn. More likely, they have superficial understanding of most common ailments and include textbook zebras now and then in hopes that it's right.

You're fixating on ms3s, I was also equally talking about ms4s. Also, I'm certain you must get some incredibly low tier students.

Wait, what? You want to know the diagnosis before you take a history? You're doing it backwards. The point is to do a thorough history and then FIGURE OUT the diagnosis. The worst doctors are the ones who claim to know the diagnosis as soon as they see the patient and direct their history only at that. That's how you miss things. That's how you get sued. That's how you develop a rep as a bad doctor.

Uh no... No one is saying you diagnose beforehand. You go into the room with a differential on your mind based on the CC and age/sex.
Otherwise we would have MIs at the top of the ddx for a 25 y/o female chest pain.

But how do you even have a ddx and ask the right questions when you can only put 2 things on that ddx? and if you don't know management, how do you even tell the patient the next steps? Being a pure h&p bot doesn't help you improve that.

Pretty damn often. Ordering tests willy nilly without a physical exam to know what you're actually looking for is incompetent. Do you diagnose your patient with a migraine when you haven't looked for papilledema? Do you diagnose your patient with a COPD exacerbation when you haven't listened to their lungs? Do you diagnose your patient with cholecystitis when you haven't palpated the appendix? Do you diagnose your patient with a tension headache when you don't know his blood pressure? Statements like the one above are why we're telling you you have A LOT to learn and your posts on here are quite troubling because you're totally oblivious to how much you have to learn. The best medical students are those who know they have a bunch of scraps in their toolbox and that no skill is actually good enough to discard it.

I didn't say we're ending all physical exams... but lets be real. Tons of abdominal pain complaints with variable PEs get the CT anyway. Same with (insert X chief complaint). You're talking about the ideal situation, but real world... imaging has taken over.

Most of the midlevels I've seen know way more than an average MS3, hate to break it to you. They may not know more than a doctor after a year or two of residency, but that's a different story. I maintain, you don't know what you're doing. If you did, you'd acknowledge there's a ton you don't know and the stuff you do is far from superior to anyone clinician on the wards. Also, anyone who discounts a proper H&P is clueless about the practice of medicine.

Than a fresh ms3? Sure. Than a ms4? Absolutely not, unless they have a decade of experience and even then it's within their limited scope of practice.

Midlevels do like two years of training (PAs) or online courses with shadowing (NPs). Not sure how this knowledge magically floats into their brain, but maybe you can explain??

 

[MedicineZ0Z]

The idea that MS3s should be ordering stuff (especially without cosign) is absolutely crazy. Even at really good place, when I was an intern most of us didn't really know what we were doing half the time for the first month or two and the hawk-like attentiveness of pharmacists during the transition was really important.

No med student anywhere should be ordering without a cosign. No one has proposed that idea, ever. Lets stop repeating it.

The responses in this thread are pathetic and it's the fault of you residents and attendings. If you truly believe third year medical students are that dumb, please don't ever have them again. Tell your coordinators/faculty that you're unable to handle working with them.

Yeah exactly. Funny enough, fresher med students are probably more intelligent than residents and very likely the attendings. If they aren't performing, it's a reflection of poor teaching.

 

[Perrotfish]

The idea that MS3s should be ordering stuff (especially without cosign) is absolutely crazy. Even at really good place, when I was an intern most of us didn't really know what we were doing half the time for the first month or two and the hawk-like attentiveness of pharmacists during the transition was really important.

That's kind of the point. You don't learn how to order things until you start placing orders, and right now interns show up not having any clue what they're doing. It would a lot safer if people were learning as MS4s carrying 2-4 patients than as Interns carrying 10-80.

 

[MedicineZ0Z]

That's kind of the point. You don't learn how to order things until you start placing orders, and right now interns show up not having any clue what they're doing. It would a lot safer if people were learning as MS3s carrying 2-4 patients than as Interns carrying 10-80.

Yeah and people finish med school without knowing how to replete electrolytes, dose common meds and so on. As you mentioned, it doesn't magically come into their head in intern year. There's a steeper learning curve for the basic stuff that they already know.

 

[Perrotfish]

No med student anywhere should be ordering without a cosign. No one has proposed that idea, ever. Lets stop repeating it.

I actually proposed it earlier in this thread. Only for MS4s

 

[Mass Effect]

The responses in this thread are pathetic and it's the fault of you residents and attendings. If you truly believe third year medical students are that dumb, please don't ever have them again. Tell your coordinators/faculty that you're unable to handle working with them.

Yes, you're right. The responses from certain med students in this thread are pathetic. Acting like you're too good to take a history or that the physical exam is not needed shows how much certain people still have to learn.

That's the excuse you always hear about midlevels. In practice, they do the exact same stuff, very often with 0 supervision. They also lack knowledge of a wide variety of very basic stuff. You not knowing this puts your whole argument into question.

And yet, they likely understand the importance of a proper H&P, which you don't.

Sure but saying you don't learn via ordering is silly. The action of writing in an order helps you learn management way more than fart in the air discussion.

You don't write anything anymore. You click a box that says "heart failure" or whatever and the order set comes up. You want to write orders, knock yourself out, but no MS 3 should be doing it in the EMR.

If you want to talk about the neuro aspect of learning and retention, I'd be happy to teach you why the action of writing something in (that counts) is what helps you learn more.

Sure thing, and then I'd be happy to teach you how an EMR order set works.

You're fixating on ms3s, I was also equally talking about ms4s. Also, I'm certain you must get some incredibly low tier students.

If you knew where I worked, you'd realize how laughable this is. No, definitely not low tier. lol

Uh no... No one is saying you diagnose beforehand. You go into the room with a differential on your mind based on the CC and age/sex

And then you do a THOROUGH H&P, understanding that CC and age/sex does nothing for you when you miss something.

But how do you even have a ddx and ask the right questions when you can only put 2 things on that ddx? and if you don't know management, how do you even tell the patient the next steps? Being a pure h&p bot doesn't help you improve that.

You ask the right questions by thinking on your feet. When someone says "I have chest pain," you don't just check the next box on the H&P. You follow up on it. This is called being a good clinician. Being a doctor isn't just about management. You have to be good at figuring out what you're managing first and the only way to do that is to get better and better at getting a good history. And your last sentence "being a pure H&P bot doesn't help you improve that (telling the patient the next steps)" shows how much you have to learn.

 

[Mass Effect]

Yeah exactly. Funny enough, fresher med students are probably more intelligent than residents and very likely the attendings. If they aren't performing, it's a reflection of poor teaching.

Do you really expect anyone to take you seriously when you say such ridiculous things? I'm beginning to think you're shadowing not because of protocol at your school/hospital, but because of your personality and attitude.

 

[MedicineZ0Z]

I actually proposed it earlier in this thread. Only for MS4s

I could see that working if ms1-ms2 wasn't all based on basic sciences and more clinical medicine was learnt.

Yes, you're right. The responses from certain med students in this thread are pathetic. Acting like you're too good to take a history or that the physical exam is not needed shows how much certain people still have to learn.



And yet, they likely understand the importance of a proper H&P, which you don't.



You don't write anything anymore. You click a box that says "heart failure" or whatever and the order set comes up. You want to write orders, knock yourself out, but no MS 3 should be doing it in the EMR.



Sure thing, and then I'd be happy to teach you how an EMR order set works.



If you knew where I worked, you'd realize how laughable this is. No, definitely not low tier. lol



And then you do a THOROUGH H&P, understanding that CC and age/sex does nothing for you when you miss something.



You ask the right questions by thinking on your feet. When someone says "I have chest pain," you don't just check the next box on the H&P. You follow up on it. This is called being a good clinician. Being a doctor isn't just about management. You have to be good at figuring out what you're managing first and the only way to do that is to get better and better at getting a good history. And your last sentence "being a pure H&P bot doesn't help you improve that (telling the patient the next steps)" shows how much you have to learn.

You miss the point on everything, no joke.

 

[sloop]

That's kind of the point. You don't learn how to order things until you start placing orders, and right now interns show up not having any clue what they're doing. It would a lot safer if people were learning as MS4s carrying 2-4 patients than as Interns carrying 10-80.

But they also don’t know a lot about medicine in ways that are not at all mediated by not writing orders but nonetheless make them dangerous prescribers.

A lot of the 3rd years I have supervised also take terrible histories. Some of them basically explain that their rationale for diagnosing depression is that the patient feels that they are depressed or something similarly stupid. They don’t actually know how to methodically elicit symptoms. Similarly, they don’t know how to methodically elicit a med history. This does get a lot better throughout 4th year.

A third year prescribing Nardil based on their terrible med rec and treatment history is very dangerous.