Midlevels stealing procedures from residents, how did it come to this?

[NicMouse64]

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Curious but what if a patient refuses to be seen by a midlevel? I've always heard of it happening but no one ever says if they comply and the physician goes in?

Not sure. I've been in situations where I've wanted to say "give me the physician", but have yet to pull the trigger on that one.

 

[MedicineZ0Z]

Not sure. I've been in situations where I've wanted to say "give me the physician", but have yet to pull the trigger on that one.

If you're ms4, maybe ms3 and certainly resident to attending - you're better off being seen by a midlevel. Once you say your position they immediately switch gears and comply with any request. Obviously not the case with physicians.
Now this works when you're medically trained.

For the general public, you're at the mercy of their diagnostic and management skills.

 

[Matthew9Thirtyfive]

Curious but what if a patient refuses to be seen by a midlevel? I've always heard of it happening but no one ever says if they comply and the physician goes in?

I’ve requested to see the physician. I have always been accommodated unless I didn’t specify prior to the appointment, in which case they will ask and I can either wait or reschedule.

 

[deleted787552]

I don't know how it works in Canada. But, I've talked to docs from Europe and Japan who are trying to secure FM residency slots here and practice rights. The stories are very morbid. I kid you not about them working 60 hrs/week, seeing 40-50 pts, and making 180-200K for PCP. Those numbers are in lie with the practicing model in Europe. They are even worse in Japan.

Then again, that kind of salary probably wouldn't be that bad if I wasn't being crushed by massive med school student loans 2-3x that amount. Also, context is everything. If that is in proportion with top paying jobs in that country then that isn't so bad. If it's lower, then that's where there's really an issue

 

[W19]

Quite often in fact. Most people know what hospitals are in the city they live in. A decent number have a preference for one over the others for some reason or another.

I understand that, but most of them wont say take me to whatever hospital when they are critically ill.

 

[VA Hopeful Dr]

I understand that, but most of them wont say take me to whatever hospital when they are critically ill.

Generally speaking, if you can vocalize what you want they will do it

 

[MedicineZ0Z]

I’ve requested to see the physician. I have always been accommodated unless I didn’t specify prior to the appointment, in which case they will ask and I can either wait or reschedule.

The only (literally only) reason patients will like midlevels is because they spend more time socializing and digging into irrelevant details.

I mean if society is taking a stance that having drastically less knowledge = better diagnosis & management... then we've had everything wrong all along. Midlevels generally have a very superficial level of knowledge that is strictly limited to the basic day to day things they see. The occasional (quite uncommon) ones with more in-depth knowledge are even more narrow as far as breadth goes.
This leads to unnecessary treatment of nothing and unnecessary workup of nothing.

Seen plenty of minor knee meniscal injuries get xrayx whereas a small wrist fracture went missed because they thought an xray is unnecessary radiation. Coughs and colds with no fever/crystal clear lungs having zpaks thrown at them but obvious pediatric infections getting no treatment.

And these are actually good examples. Nevermind all the midlevels (literally the vast majority) I've met who can't read ekgs (at all) or know indications for echos etc. But hey, we're all equal right?

 

[Matthew9Thirtyfive]

The only (literally only) reason patients will like midlevels is because they spend more time socializing and digging into irrelevant details.

I mean if society is taking a stance that having drastically less knowledge = better diagnosis & management... then we've had everything wrong all along. Midlevels generally have a very superficial level of knowledge that is strictly limited to the basic day to day things they see. The occasional (quite uncommon) ones with more in-depth knowledge are even more narrow as far as breadth goes.
This leads to unnecessary treatment of nothing and unnecessary workup of nothing.

Seen plenty of minor knee meniscal injuries get xrayx whereas a small wrist fracture went missed because they thought an xray is unnecessary radiation. Coughs and colds with no fever/crystal clear lungs having zpaks thrown at them but obvious pediatric infections getting no treatment.

And these are actually good examples. Nevermind all the midlevels (literally the vast majority) I've met who can't read ekgs (at all) or know indications for echos etc. But hey, we're all equal right?

Yeah, I'm not gonna say physicians never mess up, because they do. We had a peds EP doc miss an extremely obvious buckle fracture because she anchored hard on nursemaid's elbow despite the history not supporting that at all. But one group doesn't have to be perfect to say they provide overall better care and be safer for patients.

 

[Stagg737]

Curious but what if a patient refuses to be seen by a midlevel? I've always heard of it happening but no one ever says if they comply and the physician goes in?

Not sure. I've been in situations where I've wanted to say "give me the physician", but have yet to pull the trigger on that one.

Depends on the situation, but most commonly it's either rescheduled or they're referred to another clinic. I've seen some of the referral notes in the group I was talking about earlier and some of the venom put into them by the mid-level that the patient didn't want to be seen by would be pretty funny if it wasn't so unprofessional.

 

[MedicineZ0Z]

Yeah, I'm not gonna say physicians never mess up, because they do. We had a peds EP doc miss an extremely obvious buckle fracture because she anchored hard on nursemaid's elbow despite the history not supporting that at all. But one group doesn't have to be perfect to say they provide overall better care and be safer for patients.

If you quizzed 100 random ms4s and 100 midlevels on what a buckle's fracture even is; you'd be shocked at how many midlevels don't know. Physicians make errors of course but the stuff that midlevels don't know is often very basic and sometimes even overly basic that it's mind blowing.

Depends on the situation, but most commonly it's either rescheduled or they're referred to another clinic. I've seen some of the referral notes in the group I was talking about earlier and some of the venom put into them by the mid-level that the patient didn't want to be seen by would be pretty funny if it wasn't so unprofessional.

Any examples you remember?

 

[Giovanotto]

As an MS3 who is currently doing way more shadowing than I ever thought was gonna happen after paying 60k/year and going through 2 years of intense medical education, this thread makes my blood boil.

FYI: my school has the audacity to place me in an outpatient office for part of my Internal medicine rotation. I was doing this before being in medical school, and was probably doing more then than I am now.

 

[Stagg737]

If you quizzed 100 random ms4s and 100 midlevels on what a buckle's fracture even is; you'd be shocked at how many midlevels don't know. Physicians make errors of course but the stuff that midlevels don't know is often very basic and sometimes even overly basic that it's mind blowing.

Any examples you remember?

Nothing specific I'm willing to share beyond vague stuff. Like NPs calling patients a$$holes in their notes or saying things like "patient is no longer welcome at our clinic" type of thing (though not exactly in those words).

 

[MedicineZ0Z]

As an MS3 who is currently doing way more shadowing than I ever thought was gonna happen after paying 60k/year and going through 2 years of intense medical education, this thread makes my blood boil.

FYI: my school has the audacity to place me in an outpatient office for part of my Internal medicine rotation. I was doing this before being in medical school, and was probably doing more then than I am now.

MD or DO school?

Literally 100% of your IM rotation should be inpatient, except maybe a few afternoons in total spent in subspecialty clinics.

Shadowing in an outpatient practice is literally med school's method of filling gaps and killing time. Nothing easy than to have someone follow a doctor around seeing coughs and colds and the occasional cool complaint where you don't learn anything cause you don't get to see them first and evaluate.

 

[Giovanotto]

MD or DO school?

Literally 100% of your IM rotation should be inpatient, except maybe a few afternoons in total spent in subspecialty clinics.

Shadowing in an outpatient practice is literally med school's method of filling gaps and killing time. Nothing easy than to have someone follow a doctor around seeing coughs and colds and the occasional cool complaint where you don't learn anything cause you don't get to see them first and evaluate.

I don't care to share, but if you dig deep enough you might find the answer to your question (or I can pm). 100% agree, I have 4 weeks of this crap. It's criminal. I tried seeing if I could maybe start seeing patients on my own, but was told from "the-all-wise-attending-physician-that-medical-students-shall-not-question" that the point of this year is to just get a good sense of the different fields and what they do. Not entirely wrong, but still...

 

[MedicineZ0Z]

I don't care to share, but if you dig deep enough you might find the answer to your question (or I can pm). 100% agree, I have 4 weeks of this crap. It's criminal. I tried seeing if I could maybe start seeing patients on my own, but was told from "the-all-wise-attending-physician-that-medical-students-shall-not-question" that the point of this year is to just get a good sense of the different fields and what they do. Not entirely wrong, but still...

lol so you asked them to see patients alone and they said no?

I've seen students ask to do stuff like injections and get a "no" all the way to arterial lines and whatever else. Usually, if they don't offer it - it's a no. Hence why everyone who thinks students don't show interest in this thread automatically lose credibility. Oh and, surprised they're the same pro-midlevels ones?

Students should see each and every patient alone and do all of the documentation and tasks for that patient. That includes procedures etc. There's no other way to do a proper rotation. And the biggest component of your grade should come from the assessment & plan of patients you see alone.
Like I understand shadowing on the very first day but anything beyond that is a complete rip off.

 

[Giovanotto]

lol so you asked them to see patients alone and they said no?

I've seen students ask to do stuff like injections and get a "no" all the way to arterial lines and whatever else. Usually, if they don't offer it - it's a no. Hence why everyone who thinks students don't show interest in this thread automatically lose credibility. Oh and, surprised they're the same pro-midlevels ones?

Students should see each and every patient alone and do all of the documentation and tasks for that patient. That includes procedures etc. There's no other way to do a proper rotation. And the biggest component of your grade should come from the assessment & plan of patients you see alone.
Like I understand shadowing on the very first day but anything beyond that is a complete rip off.

Honestly, probably won't be the case for 1/3-1/2 of my rotations this year.

 

[hurtem&healem]

I don't care to share, but if you dig deep enough you might find the answer to your question (or I can pm). 100% agree, I have 4 weeks of this crap. It's criminal. I tried seeing if I could maybe start seeing patients on my own, but was told from "the-all-wise-attending-physician-that-medical-students-shall-not-question" that the point of this year is to just get a good sense of the different fields and what they do. Not entirely wrong, but still...

As an M1, I spend 1 afternoon per week with a physician at an outpatient clinic. I'm expected to see patients myself and take a history, elicit chief complaint, give shots, etc. I'm obviously not expected to come up with a full ddx and treatment plan, but my thoughts are encouraged and we discuss their validity. If all you are doing is shadowing as an M3, there is something very wrong with your curriculum and rotation site. This has nothing to do with midlevel encroachment.

 

[Giovanotto]

As an M1, I spend 1 afternoon per week with a physician at an outpatient clinic. I'm expected to see patients myself and take a history, elicit chief complaint, give shots, etc. I'm obviously not expected to come up with a full ddx and treatment plan, but my thoughts are encouraged and we discuss their validity. If all you are doing is shadowing as an M3, there is something very wrong with your curriculum and rotation site. This has nothing to do with midlevel encroachment.

Hm, I wonder if physicians have anything to do with my curriculum or rotation sites, 🙄.

It is tangentially related to the increasing consensus that the current generation of physicians are selling out. There is no way any physician can accept a medical student under these conditions and feel good about it. This isn't one rotation. I've had rotations where physicians had me shadowing NPs in an outpatient setting and didn't think there was anything wrong with that. What's more, there are deans of medical schools out there who went to medical school for pennies on the dollar and are turning around and raising tuition ~5% a year, so lets try to set the record straight about physician involvement in mid level encroachment: if it nets a quick buck today at the cost of our future, the amount of fudges that they give approaches 0.

 

[W19]

As an MS3 who is currently doing way more shadowing than I ever thought was gonna happen after paying 60k/year and going through 2 years of intense medical education, this thread makes my blood boil.

FYI: my school has the audacity to place me in an outpatient office for part of my Internal medicine rotation. I was doing this before being in medical school, and was probably doing more then than I am now.

IM should be 90%+ inpatient... You have FM that should be mostly outpatient. Even FM where attended med school is 50/5o inpatient/outpatient for 80% of the students. A few of us had the misfortune of doing all 6 wks outpatient. Do you go to a DO school?

 

[MedicineZ0Z]

As an M1, I spend 1 afternoon per week with a physician at an outpatient clinic. I'm expected to see patients myself and take a history, elicit chief complaint, give shots, etc. I'm obviously not expected to come up with a full ddx and treatment plan, but my thoughts are encouraged and we discuss their validity. If all you are doing is shadowing as an M3, there is something very wrong with your curriculum and rotation site. This has nothing to do with midlevel encroachment.

lol you'd be surprised how many ms3s and ms4s are shadowing. I think if I had a rotation the remainder of this year where I have to shadow, I'll just leave and go home. Thankfully I've arranged electives via talking to previous students.

 

[deleted87051]

Hm, I wonder if physicians have anything to do with my curriculum or rotation sites, 🙄.

It is tangentially related to the increasing consensus that the current generation of physicians are selling out. There is no way any physician can accept a medical student under these conditions and feel good about it. This isn't one rotation. I've had rotations where physicians had me shadowing NPs in an outpatient setting and didn't think there was anything wrong with that. What's more, there are deans of medical schools out there who went to medical school for pennies on the dollar and are turning around and raising tuition ~5% a year, so lets try to set the record straight about physician involvement in mid level encroachment: if it nets a quick buck today at the cost of our future, the amount of fudges that they give approaches 0.

IM should be 90%+ inpatient... You have FM that should be mostly outpatient. Even FM where attended med school is 50/5o inpatient/outpatient for 80% of the students. A few of us had the misfortune of doing all 6 wks outpatient. Do you go to a DO school?

lol you'd be surprised how many ms3s and ms4s are shadowing. I think if I had a rotation the remainder of this year where I have to shadow, I'll just leave and go home. Thankfully I've arranged electives via talking to previous students.

It sounds like you guys are describing medical schools without an adequate clinical volume to support your core clerkships. How do they get accredited?

I attended a medical school affiliated with a large public hospital in NYC. The medicine services consisted of an attending, a resident, 2interns, an M4 subintern, and 3 3rd years. The subintern functioned as an intern and the M3’s were assigned to work with either an intern or the subintern. The interns typically carried 8-10 on their service (this number would occasionally balloon to 15) and would get 3-5 admissions on a typical call day. The 3rd years would help the interns get their work done. As 3rd years we admitted patients through the ER supervised by our resident and we usually presented 3 or 4 of our intern’s patients on daily rounds which were lonnnnggg but the mainstay of our education. After 2-3 hours of rounds, we would typically follow our attending who would examine and demonstrate something on a new admission. Then we were left on our own to carry out the plans made during rounds. Really the resident was our team leader and we didn’t see the attending outside of rounds. It was our job to know about the patients and their disease process. If we were clueless, it reflected badly on the resident and intern so they made sure to buff us during prerounds so we sounded like we knew what we were talking about during rounds.

Because the hospital had terrible ancillary services, we did a lot of scut. We drew our own labs and started our own IV’s. We ran abg’s, drew blood cultures, collected sputum, urine, and stool, inserted Foley’s, etc. If we wanted a cxr, we would often have to wheel the patient down to radiology ourselves or else it would never get done. We had a house staff stat lab where we had a microscope to look at blood smears, a centrifuge to spin hemacrits, and a blood gas machine. I doubt that would still be allowed in the current regulatory climate but it was very educational. We admitted a lot of DKA, MI, CHF, sickle cell crisis, pneumonia, FUO, AIDS, TB, PCP in those days. While the interns and residents had a weekly outpatient continuity clinic, the M3’s and M4’s had a completely inpatient experience.

Seems like some core clerkships are not as engaging as they once were so I understand your frustration. I’m not sure that is a problem caused by midlevels or if it stems from a lack of clinical resources at some medical schools. Medical students need a high volume of sick patients that you get to take care of under supervision. If there were enough work and patients to go around, it probably wouldn’t matter how many midlevels there are. That’s why I emphasize in the anesthesia forum that prospective residents pick a busy, high volume place even if the lifestyle sucks.

 

[operaman]

It sounds like you guys are describing medical schools without an adequate clinical volume to support your core clerkships. How do they get accredited?

I attended a medical school affiliated with a large public hospital in NYC. The medicine services consisted of an attending, a resident, 2interns, an M4 subintern, and 3 3rd years. The subintern functioned as an intern and the M3’s were assigned to work with either an intern or the subintern. The interns typically carried 8-10 on their service (this number would occasionally balloon to 15) and would get 3-5 admissions on a typical call day. The 3rd years would help the interns get their work done. As 3rd years we admitted patients through the ER supervised by our resident and we usually presented 3 or 4 of our intern’s patients on daily rounds which were lonnnnggg but the mainstay of our education. After 2-3 hours of rounds, we would typically follow our attending who would examine and demonstrate something on a new admission. Then we were left on our own to carry out the plans made during rounds. Really the resident was our team leader and we didn’t see the attending outside of rounds. It was our job to know about the patients and their disease process. If we were clueless, it reflected badly on the resident and intern so they made sure to buff us during prerounds so we sounded like we knew what we were talking about during rounds.

Because the hospital had terrible ancillary services, we did a lot of scut. We drew our own labs and started our own IV’s. We ran abg’s, drew blood cultures, collected sputum, urine, and stool, inserted Foley’s, etc. If we wanted a cxr, we would often have to wheel the patient down to radiology ourselves or else it would never get done. We had a house staff stat lab where we had a microscope to look at blood smears, a centrifuge to spin hemacrits, and a blood gas machine. I doubt that would still be allowed in the current regulatory climate but it was very educational. We admitted a lot of DKA, MI, CHF, sickle cell crisis, pneumonia, FUO, AIDS, TB, PCP in those days. While the interns and residents had a weekly outpatient continuity clinic, the M3’s and M4’s had a completely inpatient experience.

Seems like some core clerkships are not as engaging as they once were so I understand your frustration. I’m not sure that is a problem caused by midlevels or if it stems from a lack of clinical resources at some medical schools. Medical students need a high volume of sick patients that you get to take care of under supervision. If there were enough work and patients to go around, it probably wouldn’t matter how many midlevels there are. That’s why I emphasize in the anesthesia forum that prospective residents pick a busy, high volume place even if the lifestyle sucks.

I did as many of my rotations as possible at the VA so I had a very similar experience in terms of student autonomy. I don’t my services were quite as busy but we were close. Definitely lots of scut to do transporting patients and drawing labs and then taking samples to the lab. Basically nothing really happened unless you did it yourself.

I’m not sure how different things were at our mothership. My rotations there seemed to keep students very engaged too even though we had less scut we could do.

As I look back, there was a huge difference between 3rd and 4th year with our 3rd year giving us much more sense of autonomy and responsibility. The change? We went from quasi-paper charting to epic on July 1st of my fourth year.

The EMR definitely limits student involvement and i think has probably been a big net negative for medical education. The paper charts and need to fetch results and other info from different physical locations made the student a very valuable member of the team for that alone and prevented everyone from practicing call room medicine.

There really should be minimal shadowing for clinical students. Shadowing is great for new M1s while they learn the flow and also something I’m finding very valuable as someone near the end of training so I can see how the most efficient staff move quickly through complex clinical encounters. But definitely not what a medical student needs to be doing.

 

[hurtem&healem]

As I look back, there was a huge difference between 3rd and 4th year with our 3rd year giving us much more sense of autonomy and responsibility. The change? We went from quasi-paper charting to epic on July 1st of my fourth year.

The EMR definitely limits student involvement and i think has probably been a big net negative for medical education.

A couple months back someone posted that there was a rule change coming up so medical student charting could be signed off by an attending (/resident?). That would at least make charting a real thing as a student again. Does anyone know if that actually came to fruition or if it is having any effect?

 

[235009]

The only (literally only) reason patients will like midlevels is because they spend more time socializing and digging into irrelevant details.

I mean if society is taking a stance that having drastically less knowledge = better diagnosis & management... then we've had everything wrong all along. Midlevels generally have a very superficial level of knowledge that is strictly limited to the basic day to day things they see. The occasional (quite uncommon) ones with more in-depth knowledge are even more narrow as far as breadth goes.
This leads to unnecessary treatment of nothing and unnecessary workup of nothing.

Seen plenty of minor knee meniscal injuries get xrayx whereas a small wrist fracture went missed because they thought an xray is unnecessary radiation. Coughs and colds with no fever/crystal clear lungs having zpaks thrown at them but obvious pediatric infections getting no treatment.

And these are actually good examples. Nevermind all the midlevels (literally the vast majority) I've met who can't read ekgs (at all) or know indications for echos etc. But hey, we're all equal right?

A bunch of hospital administrators with MBAs and no medical training decided that patient satisfaction is the only thing that counts. Patients now get surveys where they rate physicians and support staff all the time. Even as a trainee your patients will get satisfaction surveys...both inpatient and outpatient. The top two things that lead to patient satisfaction is feeling that they were listened to and getting what they want (usually a prescription for antibiotic or narcotic). More and more physicians and midlevels are taking the path of least resistance with the latter in order to stay on schedule of seeing a patient every 10-15 minutes. Physicians had little say in the initial decision to measure "quality" as patient satisfaction and it all goes back to healthcare as a business and seeing patients as clients/customers.

As an MS3 who is currently doing way more shadowing than I ever thought was gonna happen after paying 60k/year and going through 2 years of intense medical education, this thread makes my blood boil.

FYI: my school has the audacity to place me in an outpatient office for part of my Internal medicine rotation. I was doing this before being in medical school, and was probably doing more then than I am now.

I don't care to share, but if you dig deep enough you might find the answer to your question (or I can pm). 100% agree, I have 4 weeks of this crap. It's criminal. I tried seeing if I could maybe start seeing patients on my own, but was told from "the-all-wise-attending-physician-that-medical-students-shall-not-question" that the point of this year is to just get a good sense of the different fields and what they do. Not entirely wrong, but still...

If I remember correctly I did 4 weeks of outpatient IM as well during my 12 week rotation. Was sent to a private practice with someone who was a graduate of my med school. He let me see patients first but would just come in when he was ready. No presenting or telling him what I thought . That being said outpatient is about a quarter to a third of your training in IM residency so seems like an appropriate thing to expose you to during your rotation (in a proportional manner of course).

I've seen students ask to do stuff like injections and get a "no" all the way to arterial lines and whatever else. Usually, if they don't offer it - it's a no. Hence why everyone who thinks students don't show interest in this thread automatically lose credibility. Oh and, surprised they're the same pro-midlevels ones?

With regards to procedures - the rule is "see one, do one, teach one". There is no way in hell I'm going to let you approach a patient with a needle unless you assure me that you've practiced this on a manikin and have stood next to me (or one of the residents) scrubbed in observing and/or passing instruments. If it's an ultrasound guided procedure there will be further scrutiny of your ultrasound knowledge skills. I don't foresee myself ever "offering" a procedure to a med student on the fly. It's a process and you need to work your way up to getting to do the procedure.

Different story for interns though. Would like them to see one before doing one but I'll let an intern take a shot at it under direct supervision since they have been vetted to some extent.

 

[Goro]

Hm, I wonder if physicians have anything to do with my curriculum or rotation sites, 🙄.

It is tangentially related to the increasing consensus that the current generation of physicians are selling out. There is no way any physician can accept a medical student under these conditions and feel good about it. This isn't one rotation. I've had rotations where physicians had me shadowing NPs in an outpatient setting and didn't think there was anything wrong with that. What's more, there are deans of medical schools out there who went to medical school for pennies on the dollar and are turning around and raising tuition ~5% a year, so lets try to set the record straight about physician involvement in mid level encroachment: if it nets a quick buck today at the cost of our future, the amount of fudges that they give approaches 0.

To be accurate, G, Deans have ZERO say in the tuition dep't. That's determined higher up in the food chain, by University level Presidents/CEOs/Provost and/or Chancellors. And their CFOs, of course.

 

[MedicineZ0Z]

It sounds like you guys are describing medical schools without an adequate clinical volume to support your core clerkships. How do they get accredited?

I attended a medical school affiliated with a large public hospital in NYC. The medicine services consisted of an attending, a resident, 2interns, an M4 subintern, and 3 3rd years. The subintern functioned as an intern and the M3’s were assigned to work with either an intern or the subintern. The interns typically carried 8-10 on their service (this number would occasionally balloon to 15) and would get 3-5 admissions on a typical call day. The 3rd years would help the interns get their work done. As 3rd years we admitted patients through the ER supervised by our resident and we usually presented 3 or 4 of our intern’s patients on daily rounds which were lonnnnggg but the mainstay of our education. After 2-3 hours of rounds, we would typically follow our attending who would examine and demonstrate something on a new admission. Then we were left on our own to carry out the plans made during rounds. Really the resident was our team leader and we didn’t see the attending outside of rounds. It was our job to know about the patients and their disease process. If we were clueless, it reflected badly on the resident and intern so they made sure to buff us during prerounds so we sounded like we knew what we were talking about during rounds.

Because the hospital had terrible ancillary services, we did a lot of scut. We drew our own labs and started our own IV’s. We ran abg’s, drew blood cultures, collected sputum, urine, and stool, inserted Foley’s, etc. If we wanted a cxr, we would often have to wheel the patient down to radiology ourselves or else it would never get done. We had a house staff stat lab where we had a microscope to look at blood smears, a centrifuge to spin hemacrits, and a blood gas machine. I doubt that would still be allowed in the current regulatory climate but it was very educational. We admitted a lot of DKA, MI, CHF, sickle cell crisis, pneumonia, FUO, AIDS, TB, PCP in those days. While the interns and residents had a weekly outpatient continuity clinic, the M3’s and M4’s had a completely inpatient experience.

Seems like some core clerkships are not as engaging as they once were so I understand your frustration. I’m not sure that is a problem caused by midlevels or if it stems from a lack of clinical resources at some medical schools. Medical students need a high volume of sick patients that you get to take care of under supervision. If there were enough work and patients to go around, it probably wouldn’t matter how many midlevels there are. That’s why I emphasize in the anesthesia forum that prospective residents pick a busy, high volume place even if the lifestyle sucks.

I had an okay experience in 3rd year because I was seeing patients alone, presenting and my notes were the actual note itself for the patient's chart.
But it wasn't until 4th year where I got more hands on and that was my disappointment over ms3.

 

[Giovanotto]

To be accurate, G, Deans have ZERO say in the tuition dep't. That's determined higher up in the food chain, by University level Presidents/CEOs/Provost and/or Chancellors. And their CFOs, of course.

Physicians occupy all of those roles in medical education, no? Anecdotally I know that to be true. .

 

[sinombre]

What I'm struggling to understand is physicians are willing to offload procedures to midlevels but they won't teach students how to do these procedures? The rationale is basically to uniformly bash students for not being "interested" and "worth their time" to teach them. So they basically leave most students out to dry and have them stand around shadowing them.

For what it's worth, I've literally never seen or experienced this. At least where I am, there is no shortage of procedures (whether its lac repairs on the trauma service, a-lines, central lines, chest tubes, etc) and we make an active effort to teach students.

 

[Goro]

Physicians occupy all of those roles in medical education, no? Anecdotally I know that to be true. .

Medical education, yes. But most, if not all medical schools are part of a larger educational system, and the people running those are NOT MDs or DOs.

Those are the people I was referring to who make the tuition.

 

[762513]

It’s very understandable to be frustrated when a midlevel gets to do a procedure instead of a medical student who is there and excited to learn. However, a midlevel can’t “steal” anything. The attending decides who gets to do a procedure. Maybe the OP titled the post wrong.

 

[Giovanotto]

Medical education, yes. But most, if not all medical schools are part of a larger educational system, and the people running those are NOT MDs or DOs.

Those are the people I was referring to who make the tuition.

We can go back and forth on this, but ultimately you're skirting around the issue. Some medical schools are not part of larger education systems, i.e. lots of DO schools. And even then, there are enough MDs/DOs involved in medical education that are turning a blind eye to the rising costs of tuition. Are you telling me they have no say? Please, guilty by association until proven otherwise. It seems to me that medical students are getting attacked from every front these days, and I'd love to be wrong about this, but at the very least it feels this way.

 

[Goro]

We can go back and forth on this, but ultimately you're skirting around the issue. Some medical schools are not part of larger education systems, i.e. lots of DO schools. And even then, there are enough MDs/DOs involved in medical education that are turning a blind eye to the rising costs of tuition. Are you telling me they have no say? Please, guilty by association until proven otherwise. It seems to me that medical students are getting attacked from every front these days, and I'd love to be wrong about this, but at the very least it feels this way.

What you're ignoring is the fact that aside from schools like LECOM, medical school Dean's literally have no say in what tuition is.

What they do have some say over is how much the med school gets to keep.

Note that I wrote "some say", not "100% control over".

 

[W19]

I was in the GI service last month and I worked with a doc that is in his mid 50s and he told that GI was only 2 years when he did it. He even went further by saying GI cant be 2+2 and the GME money that is left should be used to finance more primary care residency...

 

[VA Hopeful Dr]

I was in the GI service last month and I worked with a doc that is in his mid 50s and he told that GI was only 2 years when he did it. He even went further by saying GI cant be 2+2 and the GME money that is left should be used to finance more primary care residency...

They can do more with scopes than they could 20 years ago so not sure it's a valid comparison.

 

[Giovanotto]

What you're ignoring is the fact that aside from schools like LECOM, Mexicoical school Dean's literally have no say in what tuition is.

What they do have some say over is how much the med school gets to keep.

Note that I wrote "some say", not "100% control over".

And the games continue....I love me a good ol blame game. Next time I hear an attending complain about medical student's lack of residency preparation, i'll say:

"What you're ignoring is the fact that aside from schools like X, medical students literally have no say in how their rotations turn out".

 

[hurtem&healem]

I was in the GI service last month and I worked with a doc that is in his mid 50s and he told that GI was only 2 years when he did it. He even went further by saying GI cant be 2+2 and the GME money that is left should be used to finance more primary care residency...

All the primary care specialties have ~0.5 US grads applying per residency spot. Adding in everybody else it only goes up to about 1.15 people applying per spot. Is the number of residencies really the bottleneck for PC? I'm not sold on that.

 

[Matthew9Thirtyfive]

If you quizzed 100 random ms4s and 100 midlevels on what a buckle's fracture even is; you'd be shocked at how many midlevels don't know. Physicians make errors of course but the stuff that midlevels don't know is often very basic and sometimes even overly basic that it's mind blowing.

Yeah that was my point. And when we took her to her pediatrician when she wasn’t getting any better, she figured it out in about 2 minutes. Meanwhile the NP student there told us our other kid’s ears looked good when she had a severe ear infection lol. And she was about to graduate. Anecdotal I know, but I seem to see that waaaay more in midlevels (particularly NPs) than docs.

 

[Goro]

And the games continue....I love me a good ol blame game. Next time I hear an attending complain about medical student's lack of residency preparation, i'll say:

"What you're ignoring is the fact that aside from schools like X, medical students literally have no say in how their rotations turn out".

I love the smell of cognitive dissonance in the morning

 

[MedicineZ0Z]

Yeah that was my point. And when we took her to her pediatrician when she wasn’t getting any better, she figured it out in about 2 minutes. Meanwhile the NP student there told us our other kid’s ears looked good when she had a severe ear infection lol. And she was about to graduate. Anecdotal I know, but I seem to see that waaaay more in midlevels (particularly NPs) than docs.

That's really not the exception but rather the norm. I've seen NPs a year into practice still googling common drugs that ms2s know in detail and when I say google... I mean with the intent of seeing what it even is.

You honestly don't see docs mess up basic stuff, basically ever. I'm including everyone all the way down to an intern during winter time. In my 4th year class, I honestly couldn't find anyone who wouldn't know (off the top of their head) the stuff I've seen large numbers of NPs/PAs look up.
The knowledge gap is simply enormous.

 

[Giovanotto]

I love the smell of cognitive dissonance in the morning

Me too.

 

[MedicineZ0Z]

And the games continue....I love me a good ol blame game. Next time I hear an attending complain about medical student's lack of residency preparation, i'll say:

"What you're ignoring is the fact that aside from schools like X, medical students literally have no say in how their rotations turn out".

Student "feedback" is largely useless too. Even at decent schools who value feedback by med school standards, changes are very subtle/insignificant/take forever. A bad preceptor will still be in place for like 2 years even after complaints roll in. And changes are usually done in ways that harm actual learning but seem innovative in some silly way.

Student initiative is a silly concept of its own anyway. Everything is instructed to you until suddenly you're in a position of weakness (ms3) and are expected to take the lead (lol)
For example on surgery, I had to seek out specific surgeons that allowed students to suture. Preceptor would sometimesss allow it (but not usually, ridiculous I know) and other surgeons would not. Despite us being first assist!
Same concept on every single rotation basically.
Through the same drive I got intubations, central lines, put in orders etc but most students did not.

 

[Matthew9Thirtyfive]

That's really not the exception but rather the norm. I've seen NPs a year into practice still googling common drugs that ms2s know in detail and when I say google... I mean with the intent of seeing what it even is.

Not sure where the miscommunication is happening, but yes, I agree that's the norm with NPs.

You honestly don't see docs mess up basic stuff, basically ever. I'm including everyone all the way down to an intern during winter time. In my 4th year class, I honestly couldn't find anyone who wouldn't know (off the top of their head) the stuff I've seen large numbers of NPs/PAs look up.
The knowledge gap is simply enormous.

My point is that I have seen docs screw up basic stuff, but much, much less often. Docs definitely anchor onto things, but it's not usually because they don't have the knowledge, whereas it seems like NPs (and some PAs, I'm sure) are simply just missing big chunks of knowledge. It's just reversed. There are a few docs who are totally incompetent, and there are a few NPs that are good. But those are the exceptions.

 

[Evidence Based]

A couple months back someone posted that there was a rule change coming up so medical student charting could be signed off by an attending (/resident?). That would at least make charting a real thing as a student again. Does anyone know if that actually came to fruition or if it is having any effect?

Popping into this thread to say yes this has taken effect. I'm an intern, and at my hospital med students can now write notes that are directly co-signed by the attending. Win/win since med students get more autonomy and I have fewer notes!

 

[Giovanotto]

Popping into this thread to say yes this has taken effect. I'm an intern, and at my hospital med students can now write notes that are directly co-signed by the attending. Win/win since med students get more autonomy and I have fewer notes!

Pretty sure this is also happening at the hospital I sometimes rotate at.

 

[deleted87051]

I remember this thread from long ago but couldn’t find it. Now I have. Happy to report that my lifetime Pap smears and rectal exams are in the single digits.

Procedure Numbers

 

[vernhart]

I remember this thread from long ago but couldn’t find it. Now I have. Happy to report that my lifetime Pap smears and rectal exams are in the single digits.

Procedure Numbers

well I should hope you haven't been using multiple digits for the rectal exam

 

[Matthew9Thirtyfive]

well I should hope you haven't been using multiple digits for the rectal exam

Give em the fist.

 

[Psai]

well I should hope you haven't been using multiple digits for the rectal exam

Yeah that's usually included with the premium package

 

[mehc012]

What’s also funny to me is how students want to “do” the procedure but don’t even know how to set up for it. Now THAT is a useful skill to learn: how to set up for a bedside central line or how to set up for a direct laryngoscopy and endotracheal intubation, how to bag mask well while someone sets up airway equipment.

What students and some interns usually mean by “doing” the procedure is for the senior physician to set everything up and then hand them the key instrument at the last minute so they can do whatever that move is. It’s not like the students are setting everything up beautifully and then someone else snags the procedure.

For most of these things, the setup and equipment selection is actually the most important part. It’s the primary reason I’d ask for help if I had to do one i hadn’t done in awhile so I don’t forget something stupid.

I’ve said it before- students, if you want to do procedures, ask to set up for them, to fetch the right equipment and have everything ready to go. Nobody likes setting these things up and if you do a good job, your chances of getting to do it go up significantly.

This actually frustrates me as a student - many residents won't let you do the prep, they just set everything up for you and then let you play doctor for 5s at the end, then magically do all of the nuts and bolts after. That's not helpful to me. If someone asks me "do you know how to get an ABG," I'm not going to say yes unless I know where to get the kit, how to set up to make it easiest on me, where to print the appropriate label for it, and how to package it and get it to the lab...otherwise I couldn't do it on my own. And to me, the point of practicing is to get to where you could do it on your own eventually, even if it will be a while until you're ready for it.

My favorite rotation in M3 was the trauma service, where they made it clear that I owned all lac repairs unless specifically told otherwise. Got to the point where I'd grab my setup, take it into the room, talk to the family, go get my resident, explain exactly what I was planning to do and how, and they'd look at the wound and agree or adjust ("do another deep stitch there" or "maybe 4-0 instead") and then leave me to it. I'd have them assess the final work at the end. It was one of the only moments in 3rd year where I felt as if I was actually helping both the team and the patient - the patient got fixed up quicker than if they had to wait for the resident, and the resident didn't have to do the procedure themselves.

Of course, I only got to that point because I was doing what you describe: the first time I saw a procedure, I'd make sure to follow them while they gathered their equipment and ask the reasoning for their selections. Later, whenever anyone mentioned the procedure, I'd gather the supplies and have them ready to go, which made it clear that I was familiar with the steps. One final note I'd add, though...don't openly telegraph your uncertainties! Your supervisor knows you're new to this, and they know you're incompetent. That's why they're watching you. At some point, you have to just act confident and go for it, and your preceptor will adjust your technique or give you tips along the way. The patient will freak out a lot less and be more comfortable with you doing the procedure if you seem like you know what you're doing, but are getting ongoing teaching and coaching, than if you hesitate, look nervous, and ask every simple bit each time. If your preceptor says "Alright, go ahead and do x" start doing something. Slowly, sure, so they can keep an eye on it and have time to react, but don't just stand there looking like a deer caught in the headlights.