Is scutting your students good for them?

[Anka]

It actually sounds like you could have or did learn a lot from doing it, e.g. about transfusion requirements, reasons for particular procedures, etc.

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[Winged Scapula]

For example:

On hospital day #7 the patients Hematocrit was 18 and hemoglobin was 6, and order was place to begin transfusion of 4 units PRBcs. Midway into the first unit the patient began to have chest pain, lasting for 4 minutes which was associated with diaphoresis and was of a different character of the chest pain that the patient presented with so STAT EKG was performed and serial cardiac enzymes were sent at 11:00 am. The troponin, CKMB, etc . . . results were received and came back at x, x, x, and were negative for MI. Cardiology was placed on this day and completed by 4 pm, and the cardiology fellow advised that a stress test be performed for our patient. We decided to delay the stress test until after the third blood transfusion was completed, at this time during the admission 6 units of PRBCs had been transfused over 7 days, without a source of bleeding so surgery was consulted on this day for ongoing bleeding without obvious source and continuing abdominal pain. . . .

This would be easy to write if you were there on rounds, but IMAGINE doing this for a patient you don't know!

Hmmm..while very commendable, I can honestly say I've never seen a discharge summary THAT detailed and I'm not just talking about those written by surgeons. I read plenty from our hospitalists and IM colleagues and no one, attendings included, is that detailed.

 

[RTrain]

Hmmm..while very commendable, I can honestly say I've never seen a discharge summary THAT detailed and I'm not just talking about those written by surgeons. I read plenty from our hospitalists and IM colleagues and no one, attendings included, is that detailed.

Word.

Discharge summaries don't need to have every lab value on every day, down to the hour. They're summaries. If someone wants the detailed events of every single day, they can read the chart.

That doesn't mean that's it's easy to do a discharge summary on a new patient when you just have come on service, but it's not that herculean of an effort if you follow a template and be concise.

 

[secretwave101]

I often feel guilty when I make an MS do "my" work. Because they do it, my life is easier. It feels pretty great to just sign off on an H&P with a few additions. Then I feel guilty about it and figure I scutted them out. Then I get all conflicted and pissy and start having an argument with the MS in my head, "MOST of the job is scut! If you don't like it, go sell vacuums or teach people to hit golf balls or something. You're here with me for Saturday call...you'll do scut. Deal."

Then, just when I'm all worked up and ready to throw down, I realize the MS just thanked me for giving them some real responsibility.

Conclusion: Scut's in the eye of the beholder (with the exception of coffee runs...)

 

[Substance]

Once I was asked to write a discharge summary on a patient I had meet for the first time 8 hours ago (new students rotating on to a ward), and the resident had been following the patient for two weeks. That is more like a chart review where you have to go through the chart of a paitent you don't know . . . it is best to start working on the discharge summary early, it takes forever to try to find when lines were placed and D/C'd . . . I think students should focus on the patients they have seen from the get go as much as reasonably possible. . .

Once had an intern on surgery who wasn't even a surgical intern but doing a prelim or something, I didn't now this but he made all the students sit around him as he talked about what he thought he knew about surgery and made jokes and we all felt we needed to laugh or something and I wanted to go do work because this guy was wasting our times and didn't know much more than us. It is ridiculous how once interns and second year residents get the M.D. after their name they assume that they can basically order us to do many non-patient care related activities, most don't even bother to teach.

I actually agree with you here: writing a discharge summary on a patient you've never met is totally true scut. It's only a valuable exercise if it's been your patient from start to finish.

I've only had to do a blind d/c summary on two patients because both of my residents were post, and I offered to pick up the slack. Being made to do this by a resident, however, is just abuse of power.

 

[Top Gun]

I often feel guilty when I make an MS do "my" work. Because they do it, my life is easier. It feels pretty great to just sign off on an H&P with a few additions. Then I feel guilty about it and figure I scutted them out. Then I get all conflicted and pissy and start having an argument with the MS in my head, "MOST of the job is scut! If you don't like it, go sell vacuums or teach people to hit golf balls or something. You're here with me for Saturday call...you'll do scut. Deal."

Then, just when I'm all worked up and ready to throw down, I realize the MS just thanked me for giving them some real responsibility.

Conclusion: Scut's in the eye of the beholder (with the exception of coffee runs...)

There's no reason for you to feel guilty. An H&P is not scutwork at all.
Doing a good H&P is a fundamental skill for every future physician to master. Without a good H&P, you can't come up with an assessment and plan. Doing progress notes also is not scutwork, because then you learn how to follow a patient and devise an assessment and plan as you go. Scutwork, to me, consists of menial tasks with no educational value whatsoever.

 

[Ypo.]

Darth...I wasn't disagreeing with you. I feel like doing discharge summaries can qualify as scut.

H & P's are not.

And if you've seen the patient through their whole course and been involved with their care, doing a discharge summary is not scut either. It's just that they seem to vary from site to site, whereas an H&P is always the same format.

 

[Blade28]

She hated you because you were a better student than she was. She wished she was as good at O&G as you were. I bet she was frumpy too.

Thanks.

And yes, she was.

 

[lowbudget]

I love these stories! They make the end of residency just that much sweeter.

I'm not going to let a student do jack crap until I can completely trust them. How do you expect me to instruct you through a procedure when you can't follow simple instructions I've given you on simple tasks? How do you expect me to allow you to be responsible for a patient's care if you don't know labs, don't follow up on studies, or better yet, lie about having completed tasks, lie about lab results ("oh, they were normal"), or act all sorts of ******ed?

Students who have never been scutted because their schools were cush show up to residency unprepared. They don't know how to do the simple stuff: H&P's, discharge summaries, write prescriptions, follow up on studies, stay sterile. If they're nice, your senior residents will cover for you; but after a while, your incompetence will be exposed.

In medical training, you're expected to do your job, know how to do the job of the person below you (and teach it), *and* learn how to do the job of the person above you.

If you show up unable to do the simple stuff, you've lost time that should be reserved to learning the hard stuff.

 

[swpm]

I actually agree with you here: writing a discharge summary on a patient you've never met is totally true scut. It's only a valuable exercise if it's been your patient from start to finish.

Riiight, because as an intern or resident you'll never rotate onto a service and have to piece together a coherent discharge summary from a fragmented record, sometimes without being able to talk to the guy who admitted the patient 73 days ago.

Chart review and documentation suck, they suck in the way that galactic core supermassive black holes suck, but they're necessary skills.

Someone's got to do it, you're on the team, so STFU and GBTW.

 

[Winged Scapula]

Riiight, because as an intern or resident you'll never rotate onto a service and have to piece together a coherent discharge summary from a fragmented record, sometimes without being able to talk to the guy who admitted the patient 73 days ago.

Chart review and documentation suck, they suck in the way that galactic core supermassive black holes suck, but they're necessary skills.

Someone's got to do it, you're on the team, so STFU and GBTW.

We used to have "dictation parties" on Trauma where the Chief would make everyone on service go over to Medical Records, after evening rounds, and go through all the charts with outstanding discharge summaries.

If you got lucky, you got the charts with the young healthy uncomplicated appy and could dictate it in about 30 seconds. Sometimes you got the multisystem trauma who sat in the SICU for 3 weeks.

Yeah, unfortunately, ESPECIALLY at the end of the year, some of your colleagues will shaft you and leave you a pile of dictations on someone you've never met.

 

[DarthNeurology]

We used to have "dictation parties" on Trauma where the Chief would make everyone on service go over to Medical Records, after evening rounds, and go through all the charts with outstanding discharge summaries.

If you got lucky, you got the charts with the young healthy uncomplicated appy and could dictate it in about 30 seconds. Sometimes you got the multisystem trauma who sat in the SICU for 3 weeks.

Yeah, unfortunately, ESPECIALLY at the end of the year, some of your colleagues will shaft you and leave you a pile of dictations on someone you've never met.

Some hospitals in Arizona use the "stat discharge summary" system or procedure where you have to dictate the discharge summary like the day of discharge, no ifs ands or butts. I am used to writing very long and complicated discharge summaries, when I saw a resident do one of these stat discharge summaries I was really surprised how superficial it was, i.e. didn't list some imaging procedures, didn't really go exactly chronologically, just sort of sat there with the chart and winged it. If discharge summaries aren't done in time for outpatient follow-up then it is useless clinically from a non-medico-legal standpoint. While listing the discharge diagnosis and discharge medications is helpful, it might be good to have a good discharge summary for a complicated patient as perhaps some investigative options were missed.

 

[Winged Scapula]

Some hospitals in Arizona use the "stat discharge summary" system or procedure where you have to dictate the discharge summary like the day of discharge, no ifs ands or butts. I am used to writing very long and complicated discharge summaries, when I saw a resident do one of these stat discharge summaries I was really surprised how superficial it was, i.e. didn't list some imaging procedures, didn't really go exactly chronologically, just sort of sat there with the chart and winged it. If discharge summaries aren't done in time for outpatient follow-up then it is useless clinically from a non-medico-legal standpoint. While listing the discharge diagnosis and discharge medications is helpful, it might be good to have a good discharge summary for a complicated patient as perhaps some investigative options were missed.

I am new to Arizona so what is common practice in hospitals here is not really relevant to what I did in training in other states where those rules don't apply.

Obviously a detailed discharge summary is nice, but there has to come a point when taking hours to go through a chart to create a summary on a patient you don't know is not a good use of your time. In a hospital with an EMR, all the investigate studies and lab results are available on-line, so I see little use to spend hours typing in a daily listing of lab results or CT scan reports.

 

[Substance]

Riiight, because as an intern or resident you'll never rotate onto a service and have to piece together a coherent discharge summary from a fragmented record, sometimes without being able to talk to the guy who admitted the patient 73 days ago.

Chart review and documentation suck, they suck in the way that galactic core supermassive black holes suck, but they're necessary skills.

Someone's got to do it, you're on the team, so STFU and GBTW.

Riiiiight.

See, as a resident, you are being paid to do this. Sure, it sucks, but its your job. If you don't enjoy it, and it seems NO resident enjoys it, then gather together and lobby for better treatment at your jobs. Bytchin about it won't change anything. Bullying medical students will only make you resentful and a horrible person. It seems many of the residents are stuck in the whole "if I suffered than the next guys down will too" attitude. Nothing will change if this is the prominent attitude.

Medical students are paying top dollar to learn medicine, not make life easier for residents. Sure this statement will end up generating a whole bunch of "WTF kind of attitude is that?" responses, but its true. It's far more important that a student graduate with prime knowledge of human disease and treatment. Knowing where something is in a chart = nowhere near as important.

Essentially, if you can hire a secretary to do it, its not relevant from a medical education standpoint.

 

[Tired]

Medical students are paying top dollar to learn medicine, not make life easier for residents.

Yes, but you're not paying me, so either help out or get out. You want to whine about how you're paying to learn? Then go snivel to the attendings who're actually cashing your check.

 

[Tired]

If you got lucky, you got the charts with the young healthy uncomplicated appy and could dictate it in about 30 seconds. Sometimes you got the multisystem trauma who sat in the SICU for 3 weeks.

I don't mind.

"Following ______, the patient was admitted to the Surgical Intensive Care Unit. Please see the medical record for the full details of the admission. In summary, the patient was managed by the trauma service until deemed stable enough for transfer for the floor."

 

[Trifling Jester]

For example:

On hospital day #7 the patients Hematocrit was 18 and hemoglobin was 6, and order was place to begin transfusion of 4 units PRBcs. Midway into the first unit the patient began to have chest pain, lasting for 4 minutes which was associated with diaphoresis and was of a different character of the chest pain that the patient presented with so STAT EKG was performed and serial cardiac enzymes were sent at 11:00 am. The troponin, CKMB, etc . . . results were received and came back at x, x, x, and were negative for MI. Cardiology was placed on this day and completed by 4 pm, and the cardiology fellow advised that a stress test be performed for our patient. We decided to delay the stress test until after the third blood transfusion was completed, at this time during the admission 6 units of PRBCs had been transfused over 7 days, without a source of bleeding so surgery was consulted on this day for ongoing bleeding without obvious source and continuing abdominal pain. . . .

No offense to you, but I would hate to be stuck in clinic trying to understand what happened during my patient's hospital stay from that dictation.

Divide it by systems/problems and keep it simple. Chronologically based dictations make it very difficult to find out what was done for each problem.

GI: patient with GI bleeding without obvious source. Patient underwent several transfusions and surgery was consulted...

Cardio: patient with nonspecific chest pain and negative enzymes/EKG's cardiology service consulted and patient to undergo stress after resolution of GI bleed...

-The Trifling Jester

 

[CouchPotato]

I don't mind.

"Following ______, the patient was admitted to the Surgical Intensive Care Unit. Please see the medical record for the full details of the admission. In summary, the patient was managed by the trauma service until deemed stable enough for transfer for the floor."

Exactly what I was think. Its a little different as a resident that when I was a medical student. Now I need to have rounded and have dismissal summaries and admit notes done by 7:30 am so that I can get to the OR.

Also, the summary should have everything a physician later would need to know without anything extra. Does it make a difference that their K was 2.8 one day and 3.0 the next? I think it would be enough to say "The patient had persistent hypokalemia as low as 2.8 that required daily repletion." If the hypokalemia was from a ton of lasix, it may not be worth mentioning at all. If they got daily chest xrays in the unit, only include a significant one that may have an impact on later care.

I think a great summary sentence is: "The patient was transferred in and out of the ICU several times for respiratory distress requiring intubation and for hypotension requiring pressor support."

I can't count the times I've tried to read a wordy dismissal summary only to get frustrated that I can't make a story out of it in 2 minutes or less.

 

[Substance]

Yes, but you're not paying me, so either help out or get out. You want to whine about how you're paying to learn? Then go snivel to the attendings who're actually cashing your check.

Good argument.

The big problem with snivelling to the attendings is the subjectivity of student evaluations. Student's can't voice their opinions without being destroyed on evaluations. It's truly unfortunate that this is the case, as it cripples the betterment of medical education.

In my opinion the education of a medical student isn't given much value, nor is the work and learning of a resident. Instead, the resident becomes a slave to a hospital's risk-management department. The medical student gets caught up in this game of avoiding medicolegal pitfalls. Patient care takes a backseat to filling out neverending documentation primarily for medicolegal purposes.

When will doctors, residents, and students get back to learning and practicing medicine?

 

[MediCane2006]

I went to a fairly "old-school" med school. I got scutted endlessly as a med student. I had to see all the patients on the service every morning before the intern got there. I was the first person in the clinic and the last one to leave. I worked every bit as hard as the interns (if not harder), I NEVER got sent home early on call (okay, almost never)....and yes, there were times that I was miserable (esp on ObGyn, and even on surgery a few nights). But the fact that my residents expected me to function as a member of the team (albeit the lowest member on the totem pole) gave me the confidence and motivation to work harder than if I were treated as an ancillary member who was just there to "observe and learn".

My residents scutted me, but they also gave me responsibilities and made me accountable for my patient's care. I learned how to be organized, how to work up all kinds of common problems , how to be efficient about scutwork and how to prioritize clinical tasks. And when I started my surgery internship, I knew exactly what I was getting into - not only that, but I already had a headstart on a lot of the basic clinical skills that the other interns had to learn from scratch.

So, while I admit I have a hard time putting responsibility on the shoulders of my students, I really think it's depriving them of a very valuable learning experience to cherry-pick out only those clinical experiences that we think will be "good learning experiences". Being part of a team, doing scutwork, and learning all the little day-to-day skills that residency entails, is a vital part of the clinical clerkship experience and we shouldn't try to shelter our students from them.

 

[Ypo.]

So, while I admit I have a hard time putting responsibility on the shoulders of my students, I really think it's depriving them of a very valuable learning experience to cherry-pick out only those clinical experiences that we think will be "good learning experiences". Being part of a team, doing scutwork, and learning all the little day-to-day skills that residency entails, is a vital part of the clinical clerkship experience and we shouldn't try to shelter our students from them.

Just to play devil's advocate, though...it would be interesting to see a study comparing students from your school to students from a non-scut school at the end of their intern year to see if there was any difference in functioning. Intern year is going to suck, period. I only need to do so much scut work before I get the drift and after that it's just overkill. One can learn to function like an intern (ie time management-wise) by doing several sub-i's in their fourth year.
I haven't been as busy as the interns for the majority of this year, and thank goodness for that. I feel it's important to do a lot of reading to understand the reasoning behind clinical decisions.

I should add as a disclaimer that I've also been treated with "kid gloves" which basically relegated me to shadowing. In these cases I would vastly prefer scut work. Even going out to pick up someone's laundry would be better than that.

 

[haveaniceday]

I went to a fairly "old-school" med school. I got scutted endlessly as a med student. I had to see all the patients on the service every morning before the intern got there. I was the first person in the clinic and the last one to leave. I worked every bit as hard as the interns (if not harder), I NEVER got sent home early on call (okay, almost never)....and yes, there were times that I was miserable (esp on ObGyn, and even on surgery a few nights). But the fact that my residents expected me to function as a member of the team (albeit the lowest member on the totem pole) gave me the confidence and motivation to work harder than if I were treated as an ancillary member who was just there to "observe and learn".

My residents scutted me, but they also gave me responsibilities and made me accountable for my patient's care. I learned how to be organized, how to work up all kinds of common problems , how to be efficient about scutwork and how to prioritize clinical tasks. And when I started my surgery internship, I knew exactly what I was getting into - not only that, but I already had a headstart on a lot of the basic clinical skills that the other interns had to learn from scratch.

So, while I admit I have a hard time putting responsibility on the shoulders of my students, I really think it's depriving them of a very valuable learning experience to cherry-pick out only those clinical experiences that we think will be "good learning experiences". Being part of a team, doing scutwork, and learning all the little day-to-day skills that residency entails, is a vital part of the clinical clerkship experience and we shouldn't try to shelter our students from them.

I agree 100% with this post. I go to one of those med schools that treats med students with kid-gloves more often than not, especially on rotations (I guess there is a dark history of some past students being quite miserable here, to the detriment of their health/life). It can actually be quite frustrating, and definitely enhances the wall of animosity that can exist between the residents/students.

There needs to be a balance between the old school and new school. Which, IMHO, really just means that med students need to act and be treated like the adults they are. People work hard and do "scut" in most careers out there, and med school is definitely more of a vocational school than anything...with the goal of being able to do the JOB upon graduation.

 

[RTrain]

Just to play devil's advocate, though...it would be interesting to see a study comparing students from your school to students from a non-scut school at the end of their intern year to see if there was any difference in functioning.

I think more the point would be to compare students from a non-scut school and a traditional school at the beginning of intern year. At the end, hopefully everyone has learned what they need to in order to be a resident. But at the beginning, when the learning curve is so steep you're in danger of rolling off and breaking your neck, a headstart on the skills you need can make a huge difference.

 

[DrDawg]

Some hospitals in Arizona use the "stat discharge summary" system or procedure where you have to dictate the discharge summary like the day of discharge, no ifs ands or butts. I am used to writing very long and complicated discharge summaries, when I saw a resident do one of these stat discharge summaries I was really surprised how superficial it was, i.e. didn't list some imaging procedures, didn't really go exactly chronologically, just sort of sat there with the chart and winged it. If discharge summaries aren't done in time for outpatient follow-up then it is useless clinically from a non-medico-legal standpoint. While listing the discharge diagnosis and discharge medications is helpful, it might be good to have a good discharge summary for a complicated patient as perhaps some investigative options were missed.

never been in a hospital in AZ. I never did a discharge summary before internship. At first they were long and complicated. I would go day by day. After awhile I tried to go by the systems approach. Then a smart chief told me that no one reads a 12 page discharge note. No one has the time, at least I never did. The goal is to deliver a short summary of the patients hospital stay.

 

[swpm]

Medical students are paying top dollar to learn medicine

What you apparently fail to grasp, is that documentation of care delivered is part of the practice of medicine.

Enough with the endless bitching and moaning about being assigned a perfectly appropriate task. Worse, you have the gall to whine that your tuition entitles you to pick and choose only the pleasant, sunshine and butterfly, emotionally rewarding tasks. If you were on my team on one of the rare months I do inpatient work, I probably would find some meaningless scut for you - simply to get you out of my personal space.

STFU and GBTW. A discharge summary is not a errand to fetch coffee or laundry.

 

[Blade28]

Word.

Discharge summaries don't need to have every lab value on every day, down to the hour. They're summaries. If someone wants the detailed events of every single day, they can read the chart.

That doesn't mean that's it's easy to do a discharge summary on a new patient when you just have come on service, but it's not that herculean of an effort if you follow a template and be concise.

I think sometimes people forget what the purpose of a discharge summary is.

It's for the next person to read when the patient returns to the ER and needs to be admitted - that next resident will read the discharge summary to see all the pertinent events that occurred during the patient's last hospital stay.

 

[Substance]

What you apparently fail to grasp, is that documentation of care delivered is part of the practice of medicine.

Enough with the endless bitching and moaning about being assigned a perfectly appropriate task. Worse, you have the gall to whine that your tuition entitles you to pick and choose only the pleasant, sunshine and butterfly, emotionally rewarding tasks. If you were on my team on one of the rare months I do inpatient work, I probably would find some meaningless scut for you - simply to get you out of my personal space.

STFU and GBTW. A discharge summary is not a errand to fetch coffee or laundry.

You really gotta cheer up, bro. Seems you're suffering from the whole revenge syndrome: if I did it, then everyone after me should do it too! wahhh wahhh wahhh.

I would hope you send me off for some scut to do, since you don't seem to be the most pleasant of individuals to be around. Nobody likes a grump.

And what's this about emotionally rewarding tasks? I don't give a damn if its emotionally-rewarding. I care if it is medically relevant knowledge. You clearly are letting your anger in life influence what you read.

Documentation of patient care is important. Knowing medicine is far more important. Now I'm not saying that students should not do H&Ps, progress notes, or clinic work. Heck, this is very important in the growth of a medical student. Applying medical knowledge to real world situations is extremely beneficial. Writing appropriate admits etc. is important because it represents the knowledge base of the students, and can be objectively evaluated.
Reading films is also extremely medically relevant and not scut.

My definition of scut is something that has no medical relevance aka something a secretary could do. Transfer forms, home care forms, PT/OT forms, forms to set up outside non-medical consultations, STAT discharge summaries on patients you've never met, photocopying a ton of paperwork for rounds - that's scut. That's useless busywork for a medical student. Heck, residents shouldn't be doing this either: this is for secretaries to do. Unfortunately, we've let MDs become an undervalued member of the workforce that can be slaved around by insurance companies and lawyers. The fact that residents all think scut is ok doesn't fix the problem. If only residents would realize they are being used for secretary work half of the time...

 

[RTrain]

I think sometimes people forget what the purpose of a discharge summary is.

It's for the next person to read when the patient returns to the ER and needs to be admitted - that next resident will read the discharge summary to see all the pertinent events that occurred during the patient's last hospital stay.

Agreed. I lose patience with intensely detailed, strictly chronological discharge summaries. Events, procedures, consultants, discharge medications, follow-up plans - that's what I need at 3:00 am in the ER when medical records won't bring up the old chart.

 

[Blade28]

Agreed. I lose patience with intensely detailed, strictly chronological discharge summaries. Events, procedures, consultants, discharge medications, follow-up plans - that's what I need at 3:00 am in the ER when medical records won't bring up the old chart.

Exactly. Patient had an allergic reaction to a blood transfusion, developed respiratory failure and had to be intubated, or was noncompliant with PT/OT? Important to put in the discharge summary.

Patient had a routine Foley removed two days before discharge or was given K-Dur for a potassium of 3.4? Not so important.

 

[Anka]

About the d/c summary -- the fact that Darth Neurology didn't know what was and was not important enough to put into a discharge summary is illustrative of it's educational value. Let's face it, the first time you write a note of any sort, you include a bunch of stuff you don't need. You do 10-20 of them, and realize that you can do it more efficiently if you leave out certain things. So, you do. And pretty soon, you figure out what is and is not important. It's educational. It may suck to write a discharge summary on a patient you don't know, but it sounds like Darth Neurology probably learned something.

On to a totally different theme -- I'm totally sympathetic with residents who invoke the academic contract, i.e. you do the work you can do (which as a medical student is somewhat limited), and I'll teach you what I can teach you. You want me to draw blood on twenty patients, do your discharge summaries, preround on the entire service? I'll do it, and I'll neither complain nor feel abused. But teach me something, or tell the cheif I'm good help so he'll throw me a bone in the OR.

Anka

 

[Tired]

The big problem with snivelling to the attendings is the subjectivity of student evaluations. Student's can't voice their opinions without being destroyed on evaluations. It's truly unfortunate that this is the case, as it cripples the betterment of medical education.

You just said that you don't care about all my scut work, and don't feel like you should have to help. Given that, why would you think I care about your evaluation or the attending's opinion of you? I can (and do) go to bat for students come eval time. But once you make it clear that you're here to learn, not to work, then go take care of yourself; I'm too busy to care.

I never try to convince med students (in real life) that they should care about learning hospital processes and help out with the team's work. If they don't care, I want them to go home, and I'm no longer interested in giving them a hand.

Quid pro quo, my friend. Like I just pointed out to you, I don't get a cut of your tuition check.

 

[Substance]

You just said that you don't care about all my scut work, and don't feel like you should have to help. Given that, why would you think I care about your evaluation or the attending's opinion of you? I can (and do) go to bat for students come eval time. But once you make it clear that you're here to learn, not to work, then go take care of yourself; I'm too busy to care.

I never try to convince med students (in real life) that they should care about learning hospital processes and help out with the team's work. If they don't care, I want them to go home, and I'm no longer interested in giving them a hand.

Quid pro quo, my friend. Like I just pointed out to you, I don't get a cut of your tuition check.

What you are saying makes total sense, and it also illustrates the huge problem we have with medical education in the clerkship years.

There is no incentive for residents and attendings to provide any education to their students. However, there is an expectation of students to provide their time to take part in the scut. This kind of arrangement is ridiculous: any business that ran itself in such a way would be out of workers pretty quickly.

I don't whine about scut while on a rotation. I do everything that is required of me on the rotations out of fear of a bad evaluation if I bring the inefficiencies of the service to attention. How are things ever going to improve if students can point out what the problems are?

There are far too many residents and attendings who will never teach students but will cut them down on evaluations if there's any dissenting, or if they don't like their eye color. I've been with residents and attendings who did not teach a lick but expected me to scut myself to hell. I find that pretty low.


I think there should be an expectation, obligation, and incentive(aka money) for residents and attendings to teach the art to the up-and-comers. Of course, its hard to teach when you're stuck in a room for hours on end filling out a bunch of asinine forms so that the hospital does not get sued.

The main problem is that the medical system, both employment and education, is severely inefficient!!! The culture is stooped in backwards traditions that hold back the development of physicians and hinder the smooth operation of their duties. Political power in the medical field is almost nonexistent.

 

[deleted109597]

Discharge summaries need only 1. Admission diagnosis/es, 2. Discharge diagnosis/es, 3. MAJOR PROCEDURES. That's pretty much it. The rest of that stuff they can look up. They just want to know why you were in the hospital, not what course your hyponatremia took.
I had a MSOF/SIRS pancreatitis patient that was in the ICU for a month. Summary was not much more that that sentence I just wrote.

Oh, and D/C summaries are scut. Just like making a list for your chief with vitals on it, or the days labs, or anything else that keeps someone else from having to do it. When I was a subI, every morning I would have a new patient or 4 that would be getting discharged that day so that I would do the summaries.

Personally, I just wish my medical student would stop doing things like showing up late every day, only rounding on one patient, and writing notes after mine. What, are you cosigning my note?

 

[swpm]

You really gotta cheer up, bro. Seems you're suffering from the whole revenge syndrome: if I did it, then everyone after me should do it too! wahhh wahhh wahhh.

This is just one more thing you think you understand, but don't.

My philosophy as an intern and resident has always been to set up my juniors for success - to prep them so they look good in front of the attending, to get them involved in procedures, to make their time in the hospital as high yield as possible. I teach, and I'm good at it. (I'm modest, too. Perhaps the humblest resident on SDN.)

My definition of scut is something that has no medical relevance aka something a secretary could do.

Students at any level, residents included, sometimes lack the perspective and experience to understand what is relevant. This is why we have seniors (whether that person is an intern, resident, fellow, or attending) to direct us. Just because somebody else CAN do something doesn't mean YOU can't learn something from it.

You're putting an awful lot of energy into stamping your feet about how you shouldn't have to write a discharge summary. There's a difference between being told to do something unpleasant but necessary to get a patient out of the hospital, and being told to fetch coffee, walk a dog, or wash a car. Yes, much of the documentation we do is clinically irrelevant crap done for medicolegal reasons. You still have to learn how to do it well and efficiently.

The fact that residents all think scut is ok doesn't fix the problem. If only residents would realize they are being used for secretary work half of the time...

To sum up, here we have a medical student who still doesn't understand the utility and importance of learning how to document efficiently ... claiming that all residents don't understand the work they're doing. Irony ...

Pretending that the tuition check you write qualifies or entitles you to direct every detail of your education is just silly.

 

[Ypo.]

I think more the point would be to compare students from a non-scut school and a traditional school at the beginning of intern year. At the end, hopefully everyone has learned what they need to in order to be a resident. But at the beginning, when the learning curve is so steep you're in danger of rolling off and breaking your neck, a headstart on the skills you need can make a huge difference.

You're probably right about that.


Ironically; today I got assigned to do a discharge patient whom I had never met before. And to make it worse, there was no H&P in the chart, so I had to try and piece it together all from SOAP notes.

 

[Tired]

Discharge summaries need only 1. Admission diagnosis/es, 2. Discharge diagnosis/es, 3. MAJOR PROCEDURES. That's pretty much it. The rest of that stuff they can look up.

Not quite. I have never seen a discharge summary that didn't include "Hospital Course" in it. You do have an obligation to at least summarize the diagnostic/treatment course and major complications. Nothing worse than looking at a previous D/C summary for a patient who was in-house for 3 weeks, only to see what you describe above.

Personally, I just wish my medical student would stop doing things like showing up late every day, only rounding on one patient, and writing notes after mine. What, are you cosigning my note?

I actively encourage my Chief to let our current med student go home early. If you don't want to be there, you shouldn't have to be. And if you don't want to be there, I shouldn't have to put up with you.

 

[roja]

Interesting. here is my .02.

There is work and there is scut. There is definately a difference.

Within the realm of work:
-rounding
-writing notes
-following up on labs
-*helping* do paperwork on thier patients that should be supervised by residents.
-procedures
-READING

SCUT
-writing a resident's notes.
-getting labs on patients that aren't theirs.
-things to be done to make a resident's life easier and has no educational value to the medical student.


Like it or not, medical students are there to learn medicine. Reading is important. They should be reading about thier patients.

Just as they should be team players and help out, residents should be team players and not take advantage of them. If I saw one of my residents scutting a medical student, it would necessitate a long conversation about professionalism and behavior.

Its a fine line, but no one should be scutted because you were scutted. If you don't want to educate residents, don't do a residency where there are medical students.

 

[Tired]

Just as they should be team players and help out, residents should be team players and not take advantage of them. If I saw one of my residents scutting a medical student, it would necessitate a long conversation about professionalism and behavior.

If you're really an attending, then you now how the title of King Hypocrite on SDN.

Guess how quick I'd finish the scut paperwork on your patients after your "long conversation about professionalism and behavior"? Have fun filling out your own disability forms.

 

[Mayhem]

NB: This is not directed at any particular poster but...

I've been following this thread for a while and I need to ask something: What scale are we using to measure educational value? What are the units here? Let's be real, if it had been left up to me I would have spent most of 3rd year in the library reading for ward rounds. Back then, that is what I (and most 3rd years) considered to be "educational value." On the other hand, as I get closer to graduation these people seem to believe that I should be able to do what the interns do - i.e. the stuff that somehow got left out of the Harrison's and Surgical Recall. Are you seeing the disconnect?

Most med students (me included) think that med school is all about the theory of medicine. It's not. It's an apprenticeship - they're training us to do what they do. The practice of medicine is just as important as the theory and currently the practice of medicine involves endless paperwork and other supposedly non-educational tasks. As such I think that anything an intern/resident has to do on the ward is fair game for a student. We're not going to be standing in a corner ruminating on the theory in a vacuum, we need to be able to function too.*

I follow up lab values for the entire floor (I'm on emergency medicine) because...well it's pointless to be calling haematology 20 times. Yes, I know there's a secretary but it's hardly a huge imposition to do it myself and it just is faster. I've even done the unknown patient discharge note on surgery which I can tell you was less than intellectually rewarding but shockingly, not the end of the world. One of the doctors would have had to do it at some point. Besides, it means that when I ask resident dude to explain a procedure etc he won't be too busy to help me out.

Of course, I only work for you at the hospital so the only reason i'm leaving the compound is to go home. Your laundry is your issue. But I don't think most of the requests I've gotten were all that unreasonable. Granted, that might just be my residents/interns.

* Totally my own opinion, that is probably going to start a flame war: Has anyone else noticed that it's usually the IM-minded students that complain about "scut work?" The surgery-minded ones usually accept that things need to be done.

 

[roja]

If you're really an attending, then you now how the title of King Hypocrite on SDN.

Guess how quick I'd finish the scut paperwork on your patients after your "long conversation about professionalism and behavior"? Have fun filling out your own disability forms.

I am an attending. And that would be Queen hypocrite.

I am also the new director of medical student education for my department and have just finished a medical education fellowship.

Your attitude probably warrants some redirection and I am glad you aren't one of my residents.

I don't scut my residents or medical students. I do expect them to be a member of the team (which requires them to do some 'noneducational' work) However, using medical students to make a residents life easier is unprofessional.

Medical students should offer the ease of the extra work to learn what is out there as well as because residents are overworked and are taking time to teach. but they aren't there to be anyones slave. They are there to learn medicine, not feel out your paperwork because a resident is incapable of performing thier duties.

 

[RTrain]

* Totally my own opinion, that is probably going to start a flame war: Has anyone else noticed that it's usually the IM-minded students that complain about "scut work?" The surgery-minded ones usually accept that things need to be done.

Not meaning to "flame," but I would disagree with this. I think that different fields have different types of "scut" inherent in them, and as students gravitate toward one field or another, they adjust to the scut of that field and become more understanding and tolerant of it, while becoming less tolerant of the usual scut of other fields.

For example, a student that is interested in IM might have no patience for dressing changes but would be happy to calculate free water deficit or go copy a pathology slide to present in morning report. A student interested in surgery would groan at the thought of filling in a growth chart but would cheerfully remove 200 10-0 sutures from someone's face. And so on.

 

[Apollyon]

I must reiterate a point about me walking the resident's dog. The abstract example is fine, but, in reality, my Ob rotation SUCKED, and this was a glorious opportunity to escape miraculously for an hour from an interminable night on-call, to walk around Brooklyn Heights on a lovely evening like a normal person, giving a mental middle finger to the chief resident and essentially the entire L&D nursing staff (it was the junior resident's dog, and the hospital was beyond vigilant - more like fascist - about people not walking into the hosptial (and, ergo, not having them at home) in scrubs, so I was in my street clothes).

 

[Ypo.]

For the majority of my third year, I've been "assigned" (or allowed to choose) 1-3 patients to follow in the hospital. I think this is probably the best plan for a medical student. We should theoretically be doing everything for those patients that an intern does. Because we have a lighter load than an intern, it allows for more time to study and to read up on the management of our patients.

Unfortunately...the reality seems to be that a lot of the time it doesn't work out so ideally. Because of the legal implications of being a medical student, the residents have to redo everything we do and the attending has to go over the resident's note as a priority. Trying to get the attending/resident to go over our notes slows everyone down. There is still some benefit to writing them as far as time management, but I can't say that I really learn much from anyone's input since I rarely get any.

It's been my experience that trying to do everything an intern will do will depend on who you are working with and also a lot on yourself (how proactive you are, etc...). Right now I'm working with a psychiatry resident who will not let me do anything, including interview patients (she interrupts me and takes over the H & P). She apologized once and said she took over the interview because she didn't think I'd be able to get the patient to talk (I had been able to ask one question before she took over). Last week I was functioning like a resident on the consult service; seeing patients on my own, then presenting to the attending. This week I am viewed as being incapable of doing an H&P. But that is just the nature of the beast I suppose; constantly changing schedule, having to reprove yourself every two weeks, being the low man on the totem pole. Right now I would really appreciate it if the resident I was working with would quit hogging the patients and the charts and let me take a little responsibility. Or maybe it's all my fault since I haven't figured out a way to wrestle some responsibility away from her yet, but tomorrow is my last day anyway.

The point I'm really trying to make is that once a medical student is divorced from patient care, we become disinterested and eventually can become apathetic (no matter how we try not to). Cutting us off from patient care includes sheltering us from the tasks you have to do (including scut) but it also includes not letting us interview patients, write orders, neglecting to talk with us about treatment plans, and not giving us some feedback on our notes every once in awhile. Of course solely making us do unpleasant tasks you don't want to do is not very educational, but at the same time, don't be afraid to make us do the same type of scut you do (in moderation). Think of us like mini-interns who are really naive and maybe need a little nudge in the right direction and some guidance.

Thanks.

 

[Mayhem]

A student interested in surgery would groan at the thought of filling in a growth chart...

Groan? I'd rather be burnt at the stake...point taken.

 

[Tired]

I am also the new director of medical student education for my department and have just finished a medical education fellowship.

Your attitude probably warrants some redirection and I am glad you aren't one of my residents.

As am I. Thought I detected a bit of new attending syndrome there. Congratulations on your new-found power.

I don't scut my residents or medical students. I do expect them to be a member of the team (which requires them to do some 'noneducational' work) However, using medical students to make a residents life easier is unprofessional.

You don't scut your residents? Unlikely. Every hospital in the country now has reams of paperwork, none of which contribute directly to resident/student education, and are only marginally related to the work of physicians. This includes: filling out insurance forms, disability forms, parking permit forms, assorted non-relevant "screening" forms, over-involved discharge summary sheets, etc etc. And in case you hadn't notice, a substantial number of students on SDN also consider pulling lab values, tracking down films, getting consultant reports, as part of "scut work".

I know you don't do all these things for yourself, which means your residents are doing them. So it's "unprofessional" to ask the students to help out with the team's busy work, but you think nothing of having the residents do it?

Hence the hypocrite label, which (in case it wasn't obvious) I fully stand by.

Let me show you what I mean.

Here's the last paragraph of your post.

Medical students should offer the ease of the extra work to learn what is out there as well as because residents are overworked and are taking time to teach. but they aren't there to be anyones slave. They are there to learn medicine, not feel out your paperwork because a resident is incapable of performing thier duties.

Now try it this way:

Residents should offer the ease of the extra work to learn what is out there as well as because attendings are overworked and are taking time to teach. but they aren't there to be anyones slave. They are there to learn medicine, not feel out your paperwork because an attending is incapable of performing thier duties.

Why is the former sensible and the latter ridiculous?

 

[Tired]

I must reiterate a point about me walking the resident's dog.

I've previously mentioned how I once took an attending's car to the mechanic.

Yes, it was demeaning. But man, what a nice afternoon.

 

[core0]

I've previously mentioned how I once took an attending's car to the mechanic.

Yes, it was demeaning. But man, what a nice afternoon.

Donuts in the parking garage? Repeating Ferris Buehler's day off? The possibilities are endless.
Car owner: Why is there a dead deer wedged in the grill of the car.
Me. No hablo ingles

 

[DarthNeurology]

I am an attending. And that would be Queen hypocrite. I do expect them to be a member of the team (which requires them to do some 'noneducational' work)

Medical students should offer the ease of the extra work to learn what is out there as well as because residents are overworked and are taking time to teach. but they aren't there to be anyones slave. They are there to learn medicine, not feel out your paperwork because a resident is incapable of performing thier duties.

I work very hard on rotations for nice residents doing extra i.e. non-educational related work, but it is unethical IMHO to state that students must perform clerical work, medical assistant work, nurse's aides work just because residents look "overworked." without pay basically under the threat of a bad grade.

At one hospital I was at the attending took pictures of "overworked" residents to the mall to get volunteers in the community to help these poor widdle 'ol residents (soon to be real doctors) because they are overworked. Heck I feel so sorry for the neurosurgeon earning millions of dollars that I wash his car for and wash his dog and fill OT/PT forms, and heck he was just my neighbor, worked at a hospital I never rotated at, just the awe of "gosh Mister you do surgery of people's brains?" made me in awe of his awesomeness that I would do the most menial scut (sarcasm).

In the end medical students don't get paid for the clerical work, which does take away from reading time and clinical discussions with residents (who have time to socialize a lot on many of my rotations).

Because it is non-educational the only motivation to do clerical work is living under the threat of a bad eval, students should not treat residents and faculty like royalty, we are very very hardworking as well. Some of my teachers I can not repay for their kindness and excellent lectures, such as one excellent lecturer today her lecture was worth a car wash, but for some residents who want me to do their case logs for them or other work I say no, my time is more important I have stuff to read. (This is from the 'hardest working person in the ICU' per attending when verbally bashing others and excellent clinical evals.)

Really, for a resident who needs an extra-pair of hands only and does 5 minutes of teaching a month just go to McDonald's were they work harder and order them to work for you for free because your a hardworking resident, LOL.

Many residents and are spoiled rotten and have a poor work ethic and think their job is to supervise students doing things unrelated to medical education for them. The hospital working group, while it may be called a "team" it is NOT voluntary the people who choose to work with, i.e. some attendings/residents scutt students differently, the "team" helps the physician see a ludicrous amount of patients for high pay, likewise residents get paid to see patients, student do not get paid, but worse pay a high amount for tuition . . . a Team is a group of equals generally speaking, just as a basketball team. You don't have the coach telling a little known guard to pass the ball to the superstar with the sneakers deal even though the little known guard has a good shot. No, residents go out together, attendings socialize amoungst themselves, and students get left holding the short end of the stick when something goes wrong, in no way would I describe this as a "team" I feel disgusted having to do so much worhtless non-educational work for attendings who are already well compensated for their work. If the hospital working group is a team then why do residents and attendings abuse students frequently on rotations such as ob/gyn and surgery? The analogy is really of an old fashion plantation and the master of the plantation wants the slaves to work hard for the "team" I am not so delusional to believe I am working for a team. Later on groups of attendings are teams though. This is why there needs to be 100% clear rules in place to prevent abuse . . .

 

[roja]

As am I. Thought I detected a bit of new attending syndrome there. Congratulations on your new-found power.

Nope, I am not a new attending. I have been involved in medical education now for almost a decade, in various forms. And I am fairly certain that if you are actually a director of medical education (which would be odd as a resident as is stated in your profileand from your other comments in different sections: I'm an intern whose wife doesn't have to work; From my Trauma attending during last call: ) then you would know there is almost no 'power' in that position. Its an incredibly unglamorous position that has little power at all, other than trying to fight a ridiculous culture that rarely has anything to do with education.

You don't scut your residents? Unlikely. Every hospital in the country now has reams of paperwork, none of which contribute directly to resident/student education, and are only marginally related to the work of physicians. This includes: filling out insurance forms, disability forms, parking permit forms, assorted non-relevant "screening" forms, over-involved discharge summary sheets, etc etc. And in case you hadn't notice, a substantial number of students on SDN also consider pulling lab values, tracking down films, getting consultant reports, as part of "scut work".

I know you don't do all these things for yourself, which means your residents are doing them. So it's "unprofessional" to ask the students to help out with the team's busy work, but you think nothing of having the residents do it?

Hence the hypocrite label, which (in case it wasn't obvious) I fully stand by.

Actually, I don't. Part of what I love about my field is none of us: fill out insurance forms, disability forms, parking permit forms, screening forms, discharge summaries, etc etc. In the ED, we have EMR so there is not chasing down.

We do occasionally have a death packet, which I will gladly fill out. I also fill out the occasional medical clearance forms. I see patients to ease flow and do my own paperwork without residents and I would never expect a medical student to fill out a consent, explain discharge instructions to a patient or fill out a death packet. I do expect my RESIDENTS to do this as it is part of our job. So, your assumptions are *quite* faulty. And no, I don't scut my residents. Or medical students.

Let me show you what I mean.

Here's the last paragraph of your post.

Now try it this way:



Why is the former sensible and the latter ridiculous?

And both your statements make sense. If your residents are filling out paperwork because an attending is to lazy, then there is a problem in that institution. There is a fine line between allowing residents to do paperwork because that is the reality of medicine and dumping it ALL on residents because an attending is to lazy.

So, feel free to stand by your hypocrite label. You know nothing about what I do, how I teach or anything else.

The point is the state of medical education is a disaster, both for medical students and residents. The ACGME and AAMC are desperatly trying to change this but the deeply ingrained: "I was tortured so you will be tortured" is hampering these changes.

Cognitive apprenticeship (the model medical education tries to mirror) can be a phenomenally useful educational model. But not when it is about people trying to prove how hard they worked by exacting the same behavior onto thier 'inferiors'.

 

[DarthNeurology]

Its an incredibly unglamorous position that has little power at all, other than trying to fight a ridiculous culture that rarely has anything to do with education.

The point is the state of medical education is a disaster, both for medical students and residents. The ACGME and AAMC are desperatly trying to change this but the deeply ingrained: "I was tortured so you will be tortured" is hampering these changes.

The common denominator that lubricates the interaction between attendings/residents/students is fear of bad evals, destruction of career, made to feel like an idiot on rounds, and cruel jokes. I bet it can be fixed as I did an elective in a hospital with attendings who trained in India, and although I don't like making stereotypes or generalizations, and they were super nice to everyone!, who would have thought that a cardiologist could be super nice and approachable? Although I am not Indian (caucasian), I would consider/plan to work in a hospital (there are many in NY) that have mostly/all attendings and residents from India, that is a TEAM they treat everyone with respect and really are teachers. Many U.S. bred attendings of all races are prima donas, so I think it is a cultural thing. I do not believe a word from research articles or opinions that it is a pre-ordained conclusion that medical students will be abused in most rotations. Of my top 10 attendings/teachers they are all indian, and the indian residents I worked with didn't have the air of superiority like U.S. bred residents of all races. Fascinating.