procedures in med school?

[shishi]

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I'm an M3 and I feel like I haven't had much of a chance to do procedures yet (I'm 3 rotations in). Did anyone feel this way in med school or will I be SOL once intern year comes around?

 

[Perrotfish]

You're not alone. I've always heard that at my school pretty much all the procedures you're going to do you're going to do on family medicine and electives.

 

[mumd2011]

I don't know how other med schools are but I got to do a bunch of stuff 3rd year. I think it also depends a lot on your residents and whether you act interested. If there is a procedure you want to do, make your interest obvious and be willing to watch a couple before anyone is going to let you do it yourself. I think the procedure heavy rotations at my school were Ob/Gyn and Surgery.

 

[Rendar5]

What you need to learn procedure-wise as a 3rd/4th year med student is:

1. IV placement (learn this on IM/EM. if they're not forcing you to do this, you need to force yourself. Nurses are better teachers).
2. NG tube placement
3. Stitching and knotting (doesn't matter if you learn one or two-handed. learn both and memorize the one you're comfortable with). Important even if you're not going into a stitching field. Central lines require not placement.
4. Incision and Drainage (for very basic abscesses)
5. Vaginal deliveries. If a paramedic knows how to do a basic delivery, you better know how to do one =p.

Physical Exam-wise you need to be able to do a pelvic exam

Anything else honestly is nice, but not what I'd consider a requirement.

 

[ZagDoc]

I don't know how other med schools are but I got to do a bunch of stuff 3rd year. I think it also depends a lot on your residents and whether you act interested. If there is a procedure you want to do, make your interest obvious and be willing to watch a couple before anyone is going to let you do it yourself. I think the procedure heavy rotations at my school were Ob/Gyn and Surgery.

Rather, I think it depends a lot more on the type of hospitals you rotate at. I know my friends at med schools who spend a good amount of time at "the county hospital" got to do a ton. Because its chaos and there's always too much to do.

My institution doesn't have a county hospital (just the main academic center, the VA, and community sites), and frankly it doesn't matter how interested I look, prepared I am, proactive I am, whatever... there just isn't enough volume of procedures around for the med students to feast on the scraps. Everything gets gobbled up by the residents for their required numbers.

The closer I get to intern year, the more frustrating it becomes.

 

[IHeartNerds]

1. IV placement (learn this on IM/EM. if they're not forcing you to do this, you need to force yourself. Nurses are better teachers).

The paramedics who work in our ER, boy do they know how to start an IV. Crazy good.

It probably reflects poorly on medical education that I've placed more ventrics and Licox monitors than I have IVs. 🙄

 

[Disinence2]

Here's a tip to get some IV starts in.

On surgery (Or any rotation where you think residents won't mind you disappearing for a few hours to learn IV's), Head down to the Pre-Op holding area real early in the morning. Chances are there will be 15-20 patients, maybe more, needing IV's before their surgeries.

The downside is that the nurses might be a bit rushed and not feel like teaching...

 

[SocialistMD]

What sort of procedures are you wanting to do?

IVs? Those are a dime a dozen if you just make yourself available to do them.

NG tubes? Nearly every surgery service will need at least one placed while you are on rotation, you'll just need to be more aware of what is happening on the floor. If not, ask anesthesia if you can put one in before the procedure. You'll also find ample opportunity on medicine, again, if you make yourself available.

Intubations? Again, simply ask the anesthesiologist if you can do it. If you are in a room with a more senior resident or a CRNA, they are usually very willing to teach you if you show interest.

Foleys? Nearly every abdominal operation will need one, so put it in once the patient is asleep. Furthermore, nearly every trauma patient needs a rectal exam (a "procedure" at some schools) and a foley; at my medical school, that was the med student's job.

Getting procedures is very easy, but you have to be aggressive about doing them, as they usually don't fall into your lap. Nurses do most of the things considered "procedures" for medical students, so just simply ask the nurses if you can help. Trust me, you'll want to, as when you become an intern, you'll be asked by the nurses to do the difficult procedures they couldn't get (i.e. difficult foley, IV or NG tube), so you'd better know how to do them.

 

[McGillGrad]

Bread and butter Medicine procedures done within the first 2 months of 3rd year were ABGs, bloods, IV's, male catheters, and NG tubes. Surgery had many more, depending on the surgeons.

You need to literally be there all the time to get a chance, especially when the resident coverage s a minimum to get everything you want.

 

[turkeyjerky]

Getting procedures is very easy, but you have to be aggressive about doing them, as they usually don't fall into your lap. Nurses do most of the things considered "procedures" for medical students, so just simply ask the nurses if you can help. Trust me, you'll want to, as when you become an intern, you'll be asked by the nurses to do the difficult procedures they couldn't get (i.e. difficult foley, IV or NG tube), so you'd better know how to do them.

Definitely agree with this; at least at the hospital I've been at, the nurses have always been happy to let me do this stuff--the tricky part is making sure you're around when it needs to be done. An important thing to remember, though, is that no one else is looking out for you.

Any tips on how to get more involved procedures though?

 

[McGillGrad]

Any tips on how to get more involved procedures though?

#1 tip is to "Fake it 'till you make it!"

In other words, always say yes. If they ask, have you done a thoracentesis, say YES but you would like some guidance, just in case. There are TONS of videos and instructions on how to do all of these procedures, so you'll do fine as long as you're not a *****/spaz.

This is medicine, not rocket science. You could train a monkey to do most of these procedures.

 

[Cruzinman]

I was also expected to do arterial sticks as M3 and central line placements by M4. Heel sticks on peds and LP's on adults. Basically had to do a clean adult tap to pass Neurology.

 

[IHeartNerds]

I was also expected to do arterial sticks as M3 and central line placements by M4.

Funny. Our school/hospital forbids medical students from putting in central lines. Wish it weren't so...oh, liability. (Or something.)

 

[alwaysaangel]

Depends on your school but you may find that as your third year goes on it gets better.

For us, at the beginning of the year all the interns were still trying to get their feet wet and weren't comfortable enough to teach pericentesis, LPs, etc. But as the year went on they started letting students do more. So I had IM first and did nothing, a classmate of mine did it last and had 3 LPs before it was over!

It also may get better 4th year. Some of the electives 4th year are more procedure heavy. EM comes to mind. In my 4 weeks there I got to do several OG tubes, an LP, an ultrasound guided deep vein IV (arm, not central), and a pericentesis. Anesthesia is a good one for Intubations.

But it all depends on your hospital and what you can do.

 

[Knicks]

Definitely agree with this; at least at the hospital I've been at, the nurses have always been happy to let me do this stuff--the tricky part is making sure you're around when it needs to be done. An important thing to remember, though, is that no one else is looking out for you.

Any tips on how to get more involved procedures though?

The bolded portion applies to every aspect of 'real life' (whatever that is).

 

[ANCAdoc]

More and more, the procedures we do in Medicine is decreasing as hospitals have placed this responsibility to other providers.

I have never placed an IV (or been asked) as a resident. If a nurse on the ward cannot get it, they call a superior, then ICU or ER nurse if available. Our ER nurses are trained to use ultrasound if needed. If they are busy, and it is daytime, then the PICC team gets called and they use US.

I have never placed an NG tube as a resident. I placed a corpak once and only because our VA has a rule that nurses can place NG but not corpak tubes. So, I had the charge nurse tell me how to do it the right way.

I have never placed a foley as a resident. Our nurses do this and if they have problems, traumatic placement, or cannot get it to go in, then urology gets called.


Important procedures to learn:
ABG (in our system some ICU nurses do this and as well as all RTs)
Subclavian and IJ central lines (though I'm seeing more nonurgent ones, meaning does not have to be placed overnight and can wait until morning, being placed by IR at our private hospital or simply using a PICC line)
Paracentesis/Thoracentesis (again, being done a lot more by IR)
Lumbar puncture (can consult Neurology or be done by IR)

It's important to learn those listed above, but as you can see other providers are doing them more frequently. It's nice to know how to do them in the middle of the night, but during daytime hours, we generally consult them out. Besides, in private practice it is how its done. Hospitalists in our system in general do not do those procedures. If they need central access and IR is busy, then ICU gets consulted. Good times.

 

[McGillGrad]

More and more, the procedures we do in Medicine is decreasing as hospitals have placed this responsibility to other providers.

Unfortunately, this is why mid-levels keep gaining more autonomy and consider themselves equivalent to physicians. If a GP cannot do everything a mid-level does (only better) then there is something gravely wrong with the system.

 

[ANCAdoc]

Unfortunately, this is why mid-levels keep gaining more autonomy and consider themselves equivalent to physicians. If a GP cannot do everything a mid-level does (only better) then there is something gravely wrong with the system.

I embrace midlevel providers, they have their niche. Some things we do is just a time drain that does not require 11 years of education. Hospitals are just too busy these days to have an MD go around placing IV's, foley's, lines, etc.

 

[IHeartNerds]

Unfortunately, this is why mid-levels keep gaining more autonomy and consider themselves equivalent to physicians.

If a mid-level thinks skill in putting a rubber tube up a guy's schlong makes them equal to an MD, there's something wrong with the mid-level provider, not the system.

 

[McGillGrad]

I embrace midlevel providers, they have their niche. Some things we do is just a time drain that does not require 11 years of education. Hospitals are just too busy these days to have an MD go around placing IV's, foley's, lines, etc.

I can see your point. There is no reason to spend 15 minutes taking bloods when a nurse can do it. The point that I am making is that when everyone fails, you need to do it properly and quickly. If you cannot, then there is a problem.

 

[McGillGrad]

If a mid-level thinks skill in putting a rubber tube up a guy's schlong makes them equal to an MD, there's something wrong with the mid-level provider, not the system.

People believe what they can see. They cannot see your knowledge-base or your differential skills. They see you place that impossible IV, impossible intubation or impossible cath. Just like a silverback gorilla periodically proves his leadership by defeating the next toughest male, a physician needs to periodically show the tribe his/her skills.

It is one of humanity's baser instincts, but holds true today as much as it did when we lived in caves.

 

[IHeartNerds]

People believe what they can see. They cannot see your knowledge-base or your differential skills.

This is one of many reasons I'm going into surgery. However, the gorilla thing was a little weird. I suggest getting out more.

 

[knuckles]

This is one of many reasons I'm going into surgery. However, the gorilla thing was a little weird. I suggest getting out more.

I'm at a pretty upscale hospital and it's only my 2nd week of 3rd year, but I already have done a ton, like foleys, IVs, and today I got to try an NG tube in a heavily sedated ICU patient. You gotta ask doctors/nurses if they need any help and if they can teach you procedures. You have to be proactive and can't just wait for them to come to you. You're paying for the experience and gotta request.

 

[Cruzinman]

At my teaching hospital promising M4's were allowed to do simple appendectomies with resident supervision, skin-to-skin. On M4 Neurosurgery elective students were allowed to drill Burr holes and sew up the dura at the end of the procedure. I even heard anecdotally of an M4 that was allowed to attempt to seat a Yasargil aneurysm clip on a simple PCA aneurysm.

From what I'm seeing on these boards, some of you will graduate without having done a venipuncture. We learned venipuncture as M1 biochem students.

 

[nlax30]

I agree in that most of the time you have to be proactive in asking to get involved if you want any significant experience in performing procedures. Also certainly depends on where you are, how many other students/residents are there, and the atmosphere of that particular dept, etc...

My rotations are mostly at community hospitals, some with small programs, and private docs, so luckily I'm usually not fighting a handful of other students and residents for a particular procedure.

During FP clinic my attending wanted me to do all the blood draws so that was a good bit of experience. On inpatient IM & ICU was able to do some lines, a-lines, NG's. One of my surgery months I was the only student with a private vascular surgeon so I was first assist on pretty much everything, including a couple open AAA repairs. Spent a little time with IR and while resident was on vaca for a week the attending let me do as much as I wanted... ivc filters, LE arteriograms, balloon angio, biliary drainage, thoracentesis, etc..

Don't be afraid to ask. In my experience so far, most of the time the attending is not going to actively ask of you want to do something, but if you ask and are interested then they're usually happy to show you and let you get involved.