Is your clinical training inadequate?

[drLexus]

Hi everyone,
It's been 2 months since i started 3rd year and so far have completed my neuro and psych rotations. I have to admit i am feeling EXTREMELY bored when i'm on the floors. There is a ton of downtime, and whenever I am actually doing work it is mindless paperwork (ie: copying lab values and test results from one form to another). The residents barely teach us (1-2 hrs/week total) and i essentially never have face time with the attending. Going on rounds feels ridiculous, and consists of 5 residents and another 5 med students following around 1 attending for roughly two hours.
I know we are supposed to study during "down time" but i can't help but feel rude if I just sit there and read my book all day. I try to be as proactive as I can, but it feels like pulling teeth when asking the residents for something to do and I don't want to annoy them either. Sometimes i think they'd just rather do the work themselves quickly than put up with explaining things to a med student.

My days usually go like this - I round on my 1 patient and write a note for them, round for an hour or two with the team, then lunch, and come back in the afternoon and pretend to look busy. (total time 8am-4pm)

There is just so much sitting around and doing nothing!! I wish the residents would be more active in teaching and maybe explain why certain treatments are chosen or ask us what we think or at least pimp us once in a while !!!! You can't learn how to drive a car just by sitting in the passenger seat the whole time, right?

Am i the only one that feels this way? Is there something i can do to learn more? or should i just ride this out and let the real learning begin during residency?

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[olemissbabydoc]

First problem - you've had Neuro and psych. It's gonna get better - those are notoriously some of the worst/most boring rotations. Medicine and Peds are much more interactive, as is surgery if your dept is cool. Hang in there

 

[DrSnips]

Hi everyone,
It's been 2 months since i started 3rd year and so far have completed my neuro and psych rotations. I have to admit i am feeling EXTREMELY bored when i'm on the floors. There is a ton of downtime, and whenever I am actually doing work it is mindless paperwork (ie: copying lab values and test results from one form to another). The residents barely teach us (1-2 hrs/week total) and i essentially never have face time with the attending. Going on rounds feels ridiculous, and consists of 5 residents and another 5 med students following around 1 attending for roughly two hours.
I know we are supposed to study during "down time" but i can't help but feel rude if I just sit there and read my book all day. I try to be as proactive as I can, but it feels like pulling teeth when asking the residents for something to do and I don't want to annoy them either. Sometimes i think they'd just rather do the work themselves quickly than put up with explaining things to a med student.

My days usually go like this - I round on my 1 patient and write a note for them, round for an hour or two with the team, then lunch, and come back in the afternoon and pretend to look busy. (total time 8am-4pm)

There is just so much sitting around and doing nothing!! I wish the residents would be more active in teaching and maybe explain why certain treatments are chosen or ask us what we think or at least pimp us once in a while !!!! You can't learn how to drive a car just by sitting in the passenger seat the whole time, right?

Am i the only one that feels this way? Is there something i can do to learn more? or should i just ride this out and let the real learning begin during residency?

You need to use that downtime to read. Every resident I have ever had has encouraged me to read during downtime. There's no better way to spend it.

 

[diagonal]

First problem - you've had Neuro and psych. It's gonna get better - those are notoriously some of the worst/most boring rotations. Medicine and Peds are much more interactive, as is surgery if your dept is cool. Hang in there

LOL. Bias much?

I'd literally rather murder my mom than do another medicine or peds rotation.

 

[migm]

Hi everyone,
It's been 2 months since i started 3rd year..

Here is the issue. It's not a slight against you. Residents realize you know diddly squat early 3rd year and a lot of the times they're just learning the ropes too (or teaching others what the ropes are). In the beginning of the year, there just isn't a whole lot of time/desire to teach unless someone makes an effort. My advice? Get the pocket medicine book, follow your resident around, learn how to do a focused physical exam, consider differential diagnosis for various presentations, look up treatment plans, get to know how to correct electrolytes, learn what this line does and that one, why we do one test over the other, what services are consulted for which problems, read up on your patients, learn. That's supposed to be the point of all this down time - get to know your future career. No one is going to spoon feed you anything.

 

[gimghoul]

At this point, the responsibility for learning is mostly on you.

 

[hrandani]

As far as I can tell the "hidden curriculum" of MS3/4 is that there is no actual teaching.

So far all my attendings have actually been upset if I try to ask questions about their rationale or thinking process so I just leave well enough alone.

Basically everyone expects you to know what the appropriate resources are or learn by some magical kind of medical osmosis.

 

[migm]

As far as I can tell the "hidden curriculum" of MS3/4 is that there is no actual teaching.

So far all my attendings have actually been upset if I try to ask questions about their rationale or thinking process so I just leave well enough alone.

Basically everyone expects you to know what the appropriate resources are or learn by some magical kind of medical osmosis.

Please give an example of the situation you're talking about.

 

[drLexus]

You want them to tell you their thinking process regarding treatments, but do you ever ask? Yes, they're busy, but I bet some would take the time to teach if they realize you're actually interested.

I do ask questions occasionally, but i get pretty brief, incomplete answers. I also don't want to test anyone's patience. I've been told too many times by my classmates that the #1 rule of 3rd year is "don't piss anybody off."

It really does seem like we are expected to learn everything on our own, only instead of sitting at home we have to do it while in a hospital. I simply feel as if the culture of our medical institution completely forgets about med students and wanted to know if it's only me or are we all having similar experiences.

thank you everyone for your input btw.

 

[mimelim]

There are a few things at play here. This is written to be generic, I am not implying that this all necessarily applies to you. Lets start with the obvious and work to some of more complicated.

First, there is tremendous variation at every level of medical education that is circumstance dependent (ie out of your control). The quality of your education is based on 1) The institution, 2) The rotation you are, 3) the department, 4) the attending, 5) the residency program, 6) the residents currently on service. There is obviously some overlap between each of these and I have left out some people. At the end of the day, Psychology/Neurology at your institution may be weak, your attending may be weak, the residents may be weak, the clerkship may be weak, it is difficult to evaluate the deficiency without looking at the experience in person. You may just be on a crummy rotation. Every school has them.

Second, medical school and residency after is all about self-teaching and becoming a life-long learner, not being spoon fed. If you sit around waiting to be taught, you will fall behind and be dissatisfied with your education. There are going to be good attendings and good residents, ie those that will spend the time to involve you and teach you, but to expect all of them to be great teachers or to even care about you or your education is a little naive. Attendings and residents pick their jobs/programs for a lot of reasons, and mandatory interaction with medical students is NOT high on most people's lists. The classic, "But they chose to be at an academic center instead of private practice!" Is likewise naive. There are a lot of reasons to be at an academic center, especially for residents. Your education is not always going to be and shouldn't be their number one priority.

The vast majority of your education is going to be derived from watching, then doing and then teaching others. If you aren't getting an opportunity as a medical student to watch and practice the basics, there is something wrong. If you aren't participating in differentials, patient management, procedures, you are not going to learn. If you have limited patient interaction, no opportunity to learn patient management, you shouldn't be there. It is a poor clerkship location and you should make that known in your evaluations. I was on a curriculum committee up until last year and we routinely were looking for new training sites/programs and evaluating the efficacy of existing ones. Your census seems incredibly underloaded compared to the number of people on the team. There is nothing you can do about this. It just is a bad rotation.

That having been said, there are always ways to be busy in the hospital. For psych and neuro, someone has to do the admissions, consults, stroke consults, EMGs, EEGs, ECTs, etc. If you aren't busy, find out who the resident or attending responsible for those things and ask to tag along or help for future things. As a medical student I would routinely ask the residents to give me a 10 minute head start on all of the team's consults. This obviously doesn't allow for every medical student to get the same education, but in my experience, this is where the cream rises to the top. The students that are okay with rounding on 1 patient and then going home will... go home. And the students that want to learn will find ways to get involved. I know exactly what you mean when you say that it is like pulling teeth to constantly ask the residents for something to do. It is annoying for both sides.

In my experience, the best teaching situations have a good system in place. My motto has always been that a medical student should be covering every aspect of a patient's care. No surgery should go uncovered, no consult or admission should be simply "taken care of" by a resident. (the exception being if a team is being hammered and patient care will be diminished by a medical student slowing the process down, but this next to never happens). I don't think that every resident should be expected to walk you through every consult, but they shouldn't be excluding you from the experience of working up the patient and answering some basic questions about the management.

I would be careful how you tred, the last thing you want is to step on toes/piss people off, but it is important to be proactive and not just ask, "is there anything I can help with?" Remember, residents, especially interns and 2nd/3rd year residents are not that far removed from medical school. Most of the time they aren't in any better of a position than YOU to figure out how to optimize your education. Again, if the service is really so slow that nobody is doing anything every day, then students shouldn't be on it (or at least less should be). But if medical students aren't involved in every aspect of patient care, even if purely observational, there is something wrong.

My suspicion is that things will get better on other rotations, but if you learn to be proactive now, it will serve you well on other rotations even if you are busier.

 

[mimelim]

I simply feel as if the culture of our medical institution completely forgets about med students and wanted to know if it's only me or are we all having similar experiences.

It does. You are not alone. The expectations of medical students has decreased over the years for a variety of reasons. Some good, some not so good. It simply shifts the burden of teach on the early years of residency instead of medical school. It makes interns woefully unprepared. How can you be expected to manage a fever, low urine output, abnormal lytes, agitated patients, etc in the hospital if you haven't been involved (not responsible for, but forced to think through what to do)?

 

[todds]

Hi everyone,
It's been 2 months since i started 3rd year and so far have completed my neuro and psych rotations. I have to admit i am feeling EXTREMELY bored when i'm on the floors. There is a ton of downtime, and whenever I am actually doing work it is mindless paperwork (ie: copying lab values and test results from one form to another). The residents barely teach us (1-2 hrs/week total) and i essentially never have face time with the attending. Going on rounds feels ridiculous, and consists of 5 residents and another 5 med students following around 1 attending for roughly two hours.
I know we are supposed to study during "down time" but i can't help but feel rude if I just sit there and read my book all day. I try to be as proactive as I can, but it feels like pulling teeth when asking the residents for something to do and I don't want to annoy them either. Sometimes i think they'd just rather do the work themselves quickly than put up with explaining things to a med student.

My days usually go like this - I round on my 1 patient and write a note for them, round for an hour or two with the team, then lunch, and come back in the afternoon and pretend to look busy. (total time 8am-4pm)

There is just so much sitting around and doing nothing!! I wish the residents would be more active in teaching and maybe explain why certain treatments are chosen or ask us what we think or at least pimp us once in a while !!!! You can't learn how to drive a car just by sitting in the passenger seat the whole time, right?

Am i the only one that feels this way? Is there something i can do to learn more? or should i just ride this out and let the real learning begin during residency?

I echo what people have said before, you need to get off your butt and learn for yourself. Residents will not teach you more than 1-2 hours per week. Its not their job.

You need to study the patient. Study as many patients as you can when on a medicine like service such as Neuro, Psych and Peds. Start with your patient. You may ask what that means...

Start with the chief complaint - Why did the patient come to the hospital in the patient's own words. From there, sit down for yourself with a piece of paper and come up with a very broad differential diagnosis. Go by the normal physiology of the complaints. For example "chest pain" - what has the happens physiologically for you to feel pain in the chest wall? You will think of all the organs/muscles, and the nerve fibers, bones and then think of what can happen at each step.

From your differential diagnosis, ask yourself what are THE most important questions I need to ask in my HPI, family history, ROS to bring things higher or lower in my differential. This the true art you should hope to master over the next two years. Then based on whats left on your differential after HPI, you need to lookup and find out what physical exam maneuvers can further rule out things on your differential.

What's left - you may have 2-3 potential diagnoses, then THINK FOR YOURSELF what tests you would order to rule things out/in. When looking up tests, find whats the sensitivity/specifity, how is the test done? What does it mean if its negative or positive. If its imaging, READ THE IMAGE YOURSELF without reading the report first. I don't care if you're not a radiologist, get used to looking at images and trying see abnormalities. Then see what the report says, see what you missed and thats how you'll get better at reading images.

If tests have already been done, think for yourself before what you would do then compare what was done. Any unnecessary tests, anything you may have forgot?

On rounds, present your patient with your HPI, differential and a PLAN. Emphasis on the PLAN. This is the only way you will learn. Dont wait for them to ask. You give them your plan and why. And then they will correct you and may explain why, or you will read up on your own why.

If you do all this, i guarantee it will be a lot of work in the beginning, you will have to look up quite a bit of literature but you will get the hang of it. Then once you get comfortable, start taking on more patients and make plans.

On rounds, have a chapter of a book or review article in your hands and read. There is no shame in reading. I read on rounds with a review article (that is RELEVANT to your patient), and you will be surprised that attendings often think you're doing a great job reading and this makes rounds a lot more efficient for you.

In afternoons, look up on your patient and see if your modified plan is taking its course. Study other patients and make diagnoses and plans on them and see if your senior resident/attending agrees. They probably wont agree, but thats how you'll learn. You see what they would do instead and then you go and read and find out WHY that is.

Its very easy to be in the background, just do H and P and leave the thinking up to someone else. This obviously would be boring, and it makes very little work for you, but more important your training would be compromised if you continue to stay like this especially if you continue into 4th year.

I guarantee you if you what i outlined here, by the end of medical school you will probably better than most of your interns, because unfortunately many students dont come up with plans, dont come up with differentials, dont read their own images and when they become a resident they dont know jack and end up realizing how foolish it was not practice any of that stuff when there was pretty much no consequences for getting things wrong