Meharry

[Linie]

Someone please help me understand this:

I was assigned to supervise an intern who had graduated from Meharry Med School a few months ago. It was her first inpatient rotation as a physician, so I didn't expect her to know much. But I DID expect her to know how to do a history and physical, write an admit note, admitting orders, come up with a basic care plan, and present it all to me and the rest of the team in a coherent manner. She clearly had had virtually no experience with all just mentioned, in fact she had little insight into her role in patient care at all (for example, she did not seem to be aware that she was supposed to have an admit note in the chart by the next morning, and to write a progress note everyday on all her patients).

She was very sweet, and was aware and embarassed that she had fallen short of expectations. Unfortunately I only worked with her for two call nights -- I think I could have taught her a lot. Her book knowledge was quite good, she was clearly very bright, she just needed remedial work in practical skills.

I have heard that Meharry has had some trouble in recent years with accreditation. I'm sure troubles at the school played a role in the troubles with this intern.

Could someone please tell me how the clinical years are structured at Meharry, and what the role of the student is at the affiliated hospitals? If my intern was a typical product of Meharry, Meharry needs to re-organize their clinical training program.

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[me109cito]

At my school, by the time we finish second year we are expected to know how to do a complete advanced physical exam, write-ups and do oral presentations at bedside. In fact, we have a "final exam" in which we are to do just that so we can pass the class. In the third and fourth we learn how to write the admits notes, etc

 

[Linie]

Are you from Meharry?

 

[Sheon]

It's funny I just had a conversation about this today. From what I hear from current 4th year students and recent graduates at my school, it is not uncommon for recent medical graduates to have little experience in taking a patient history, and completing a patient write-up.

Different schools have different approaches to this. From what I understand, these are not necessarily functions that you need to know as a student. It certainly isn't tested on the boards (Step 2).

 

[me109cito]

Originally posted by Linie
Are you from Meharry?

No I go to school in the northwest. Up in the corner

 

[Castro Viejo]

Originally posted by Sheon
It's funny I just had a conversation about this today. From what I hear from current 4th year students and recent graduates at my school, it is not uncommon for recent medical graduates to have little experience in taking a patient history, and completing a patient write-up.

Different schools have different approaches to this. From what I understand, these are not necessarily functions that you need to know as a student. It certainly isn't tested on the boards (Step 2).

Forget for a second that Sheon and I attend the same med school in Brooklyn, but I firmly believe that ANY medical student from ANY medical school who's graduated without knowing how to take a good history hasn't been awake over the last two years. I mean, what the hell was that kid doing during any of his clerkships? Did he never admit even one patient while on the medicine service? How about taking a psychiatric history? Not even one of those?

But, Sheon, what exactly is meant by "little experience" in taking a patient history?

 

[womansurg]

I had this same experience with a fourth year MS about to graduate from an (apparently) highly ranked osteopathic program.

He simply had no idea how to do an H&P - had never done one. No idea how to write orders, do a discharge summary or SOAP note....Turns out that on all of his rotations, he was always 'shadowing' more than participating. He was very bright, had good scores (including USMLE), and knew his stuff when you pimped him. He'd just never admitted a patient before.

After a couple of days of focused teaching and direction he became a very strong member of the team, and actually ending up honoring on that elective. I suppose he would've been a pretty weak intern if he'd not stumbled onto our service right before graduation, although he probably would've recovered quickly on his own.

I agree....students should learn to work up a patient before they start their clinical rotations: during second year. That's how my school did it.

 

[Sheon]

Tim,

"Little experience" means it isn't a formal part of the education at their school. Your reaction almost sounds surprised. Ask some of the residents here. It ain't that rare.

 

[shag]

What do you do third year, if you don't admit patients and write notes? I just finished rounds and am exausted after a fun filled call night on medicine where we admitted 7 patients and I got no sleep.

I am not trying to be funny; I'm genuinely curious what you do if you don't workup your patients during clinical yrs. We H&P new admits, and then read up on the conditions they have before rounds the next morning. Every day, we see the patients we admitted on previous days and lookup vitals, labs, consults, etc. We then write a progress note, and then a discharge summary if the patient is going home.

If you don't know how to write an H&P or SOAP notes, how do you survive as an intern. I'm a MS-III, and I was expected to be a master of these on my first day, so I had to learn quickly.

 

[mikecwru]

Is it possible that he did do them during med school but just fell off the wagon a little? I don't think doing H&Ps (well) / orders / notes, etc, are like riding a bicycle. Maybe he/she did a few cake rotations and just needed to get into the swing of things.

I know that if I do a few really specialized electives where there's a huge team and I don't do much, I come back to having to run through the ADC VAANDISML mneumonic in my head and stuff. Also, notes (not your soap note, but d/c, transfer) vary by what the team wants, so even if you've done one before you have to learn it a new way. It was just a couple of months ago that I learned how to write an ICU progress note for the first time.

The original post sounded like the intern was kind of lame, I admit, but I'm just trying to play devil's advocate. Each person comes in with different weaknesses.

mike

 

[Skip Intro]

I'm sorry to hear that someone was so ill-prepared.

For the record (and for those of you who haven't read many of my other posts), I am in the Caribbean at Ross. I am an MS2 currently in my fourth semester. I will be heading to Miami to complete an Advanced Intro to Clinical Medicine semester in January, after which I will sit for Step I.

Last semester, we began learning how to take and write-up a complete medical history. This formed a portion of our course grade. This semester, I am taking introduction to clinical medicine during which we are refining our history taking and note writing skills, along with learning how to do physical exams. We have paid volunteers who come in and let us poke and prod them every week. We also have to write SOAP notes which are turned-in for a grade. Furthermore, a large part of our ICM course is learning how to read and interpret 12-lead ECGs, something that is not specifically tested on Step I (which I'll take in May... YIKES!).

I feel that I am being prepared well. Part of my "route to MD" will require that I pass the ECFMG Clinical Skills Assessment (CSA) exam. Ross is starting early in preparing us for this, and just simply preparing us to be a doctor. Likewise, I will do all of my clinical clerkships in U.S. hospitals. I feel like I'm getting the correct, and indeed good, preparation for this.

Also, there was a JAMA study that showed that the clinical skills of IMG residents were superior to those of AMGs. As a result, the clinical skills portion of the normal U.S. licensure requirements will soon be added for AMGs. (I can provide links to back-up both of those statements, if necessary or requested.) Maybe this will ultimately help everyone who is a new physician in being a better 'advanced trainee', which is all what we ultimately are when we start our residencies, no?

So, what's my point in sharing this?

I hope each of you who's taken the time to read this story remembers to keep an open mind when you are rotating with an IMG from the Caribbean. We take our education seriously. We are not here only to get "high yield" information and to learn tricks on how to pass Step I. We are getting a good core prepartion in medicine that will hopefully form a solid foundation as we continue our clinical training in the U.S.

Likewise, I hope that this wasn't only an convenient opportunity to take a potshot at Meharry. This was only one student, and does not automatically represent the entire population. Always attempt to recognize your own bias, and treat people as individuals. This will make you a better physician.

(I apologize for the apparent hijack. )

 

[mikecwru]

I hope each of you who's taken the time to read this story remembers to keep an open mind when you are rotating with an IMG from the Caribbean. We take our education seriously. We are not here only to get "high yield" information and to learn tricks on how to pass Step I. We are getting a good core prepartion in medicine that will hopefully form a solid foundation as we continue our clinical training in the U.S.

Likewise, I hope that this wasn't only an convenient opportunity to take a potshot at Meharry. This was only one student, and does not automatically represent the entire population. Always attempt to recognize your own bias, and treat people as individuals. This will make you a better physician.

(I apologize for the apparent hijack. ) [/B]

I have worked with lots of Caribbean people and they have run the gamut of quality, just like any other MD. If the person works hard, I don't see any reason why they should work differently. This goes doubly so if the person came back in the middle to do the last two years in the US.

The only annoying habit I've seen is that they say "42 yearS-old male," which is probably technically correct... just sounds different to me.

mike

 

[Skip Intro]

Originally posted by mikecwru
The only annoying habit I've seen is that they say "42 yearS-old male," which is probably technically correct... just sounds different to me.

I don't do that.

Maybe it's a British thing?

 

[Olubalogun]

THis is my first time posting for a while (since last October, I think).

Linne, I would hate to think that that post was somehow a potshot at Meharry.

I am an MSII at Meharry. I assure you, while our administration may have logistical problems (what school doesn't), anyone who graduates from here without the requisite skills in interviewing and patient admission has indeed been asleep. With the way they are cramming this s**t down my throat, I can't imagine not being able to do this stuff in my sleep, even after graduation. They are going to make us take some sort of subject board for this stuff next semester; right now they are driving us crazy. if anything, they are too uptight about this stuff (if that is possible).

Your intern, as you yourself have said, has a good knowlege base and knows her stuff; it is possible to be knowlegable and still not be too good at the paper-pushing part (although not knowing how to conduct an interview... I'm at a loss).

Meharry has had some problems in the past (isn't Yale's surgery department about to lose accreditation?), but they are working on it and making progress. it's harder for us, because we don't have the money that some of your more uppercrusty schools have.

 

[DR]

Though I agree that it is a bit hard to imagine that someone might not be able to do the things mentioned above, I have to add a note. I think that it should be understood by some residents and interns that there are rotations where they do not let the student work at their appropriate level. I have gotten through some rotations where the residents were either complete miserable jerks and did not want the student doing ANYTHING but watching, and some others where the resident clearly did not understand how much the student should be doing. I recall one of my classmates who rotated at a different hospital than me for her medicine rotation, and they were having her admit lots of patients. At my site, my resident wanted me to be writing progress notes and rounding on my patients...but no admissions. I argued that I was being short changed since my familiarity with that skill would be lacking when time came for internship, but my pleading was met with borderline tones of "don't complain, or you'll get a bad evaluation". Another example are discharge summaries; I had never done one by end of third year, when my roommates were doing them frequently (same rotation, again different hospital). What's my point? My point is that there are students out there who are interested in learning as much as they can, and ARE learning....as much as they are allowed to , and may be looked at as not as good, or strong as their colleague when they start training for this reason. What I think needs to happen is what sounds like happened in the story above, and that is that people in medicine need to understand that medical training is incredibly varied. Instead of judging who is stronger/sharper, we need to address why the weakness exists, and help the person do better. They will do better, they got this far by being bright. I think most people outside of medicine would be shocked to learn just how inconsistent and varied medical training is. It is not as standardized as we think.

 

[Linie]

Originally posted by Olubalogun

Linne, I would hate to think that that post was somehow a potshot at Meharry.

Thank you for not assuming that my post was a potshot! No, I have no reason to dislike Meharry or to want to bash it. I'm glad that other students at Meharry are getting the kind of experience that my intern had not gotten. I heard that she was doing a lot better by the end of the rotation, which does not surprise me at all bc she is very bright. I just wish she could have had a kinder, gentler introduction to clinical skills than suddenly being the MICU intern!

 

[FionaS]

The only annoying habit I've seen is that they say "42 yearS-old male," which is probably technically correct... just sounds different to me.

Maybe it's a British thing?

Hmm... Half British perhaps?

This patient is 42 years old

OR

This is a 42 year old patient

It's all about semantics