Question for Attendings and Residents: Have students become more lazy/eager to go home to study this year since the Step 1 score change?

[deleted1139416]

On the vast majority of my rotations, my partners have been very quick to go home or to study even during the rotation work hours. During my OBGYN rotation, a resident asked via group chat who wants to see a c section with postpartum hysterectomy for placenta accreta and the five of us were eating lunch in the cafeteria and the other 4 were trying to avoid having to go so I decided to go. Meanwhile the rest of them were studying in the cafeteria the whole time. Has this been happening more this year?

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[FutureInternist]

Didn’t they make it P/F?

If so, I would think there would be less need to study since so much of the 85%-ile vs 95%-ile was such minutiae that has no bearing in real medicine 🤔

 

[cj_cregg]

Didn’t they make it P/F?

If so, I would think there would be less need to study since so much of the 85%-ile vs 95%-ile was such minutiae that has no bearing in real medicine 🤔

I think they mean on clinical rotations - theoretically, making step 1 p/f places higher importance on step 2, which people are studying for during their clinical rotations.

I haven't noticed this personally, and that sort of thing certainly still happened frequently during my days in medical school with a scored step 1.

 

[Esmolol]

The problem with clinical rotations is that sometimes there is little to no time left to put the necessary time to study and do well on shelves/Step 2 CK. At our school, on rounds, you rarely learn any board-relevant material. The rotation lectures are nearly useless. Residents are overworked and simply don't have the time/energy to teach medical students. The attendings are so far removed from the "new" boards reality that it's not even funny.

Myself, I tend to spend as much time on rotations seeing things and doing things, but during times on IM, where we just sit in the team room and watch the residents attend a Zoom meeting about SNF dispos, I bust out my Anki.

 

[NeedSomeAdviceGuy]

On the vast majority of my rotations, my partners have been very quick to go home or to study even during the rotation work hours. During my OBGYN rotation, a resident asked via group chat who wants to see a c section with postpartum hysterectomy for placenta accreta and the five of us were eating lunch in the cafeteria and the other 4 were trying to avoid having to go so I decided to go. Meanwhile the rest of them were studying in the cafeteria the whole time. Has this been happening more this year?

Lots of students just don't care to see this stuff, who can blame em.

 

[Angus Avagadro]

I'm always fascinated by many students who believe if it is not going to help me get a higher board score, then it's a waste of their time. They obviously have forgotten why they want to become a physician. These students appear to want to be the physician I choose to take care of my Mother in Law.

 

[Billiam95]

I'm always fascinated by many students who believe if it is not going to help me get a higher board score, then it's a waste of their time. They obviously have forgotten why they want to become a physician. These students appear to want to be the physician I choose to take care of my Mother in Law.

I'm not condoning it, but this is simply students responding to incentives - significant portion of rotation grade is shelf exam, can fail the rotation with a failed shelf, most of the time being an all-star medical student isn't rewarded on evaluations...

 

[Angus Avagadro]

I'm not condoning it, but this is simply students responding to incentives - significant portion of rotation grade is shelf exam, can fail the rotation with a failed shelf, most of the time being an all-star medical student isn't rewarded on evaluations...

I don't disagree. Yet, nothing makes me crazier than a medical student suggesting a learning experiemce is a waste of their time. If they knew what was important, then they would be an attending living with their own mistakes. This also goes for residents who complain about working hours. Those hours are to provide experience. I don't understand why a resident would not want to learn while on MY malpractice policy than later on while on their own.

 

[Billiam95]

Yet, nothing makes me crazier than a medical student suggesting a learning experiemce is a waste of their time. If they knew what was important, then they would be an attending living with their own mistakes.

True, but sometimes you have to take the fight right in front of you first - in this case, the shelf/step2

 

[Anakinmemer]

I don't disagree. Yet, nothing makes me crazier than a medical student suggesting a learning experiemce is a waste of their time. If they knew what was important, then they would be an attending living with their own mistakes. This also goes for residents who complain about working hours. Those hours are to provide experience. I don't understand why a resident would not want to learn while on MY malpractice policy than later on while on their own.

Maybe because a good chunk of those hours are doing YOUR and the hospitals bitch work, allowing the hospital (and possibly you) to bill substantially more while they get paid trash? Not everything residents are tasked with is a learning experience/something you need an MD for. Yet the system is designed in a way that residents have the lowest negotiating power on the totem pole and thus have to deal with things other groups don't want to deal with. At my hospital they do social work, patient transport, etc.

 

[Tangerine123]

During my OBGYN rotation, a resident asked via group chat who wants to see a c section with postpartum hysterectomy for placenta accreta

If you know what that is, how to identify it, what dangers it implies and what the treatment is, then you are fine. You don't need to see it to be a good MD.

As somebody that went into a non-surgical field:

Emergency thoracotomies and laparotomies were really exciting.

C-Sections were cool, because students always scrubbed in as 1st assistants. You we did so many that the movements become natural and the OB/GYN doesn't even have to tell you what to do. +10 points it was an emergency C-section due to fetal distress, always made the shift interesting.

The only other surgery I actually remember was a breast reduction. Just because I found it really interesting how the plastic surgeon did the flaps.

The rest? Unremarkable, forgettable.

And here I am, not sobbing every day because I never got to see a Urology surgery and how that doesn't affect my life at all as an MD/Resident.

 

[Esmolol]

And here I am, not sobbing every day because I never got to see a Urology surgery and how that doesn't affect my life at all as an MD/Resident.

I'm sure you know that but you did not miss out on much...

On the other hand... even if one goes into say IM or peds - seeing a mitral valve replacement is kinda cool! There are just some things that are cool. Period.

 

[operaman]

Haven’t noticed any change yet, but I’m sure it’s coming. Medical students tend to be high achieving smart people and they will instinctively prioritize their time to focus on what will advance their career and allow them to reach their goals. As that starts to mean maximizing step 2, then they are going to have to find ways to devote additional study time.

Since clinicals are graded, schools can probably fix this if/when it becomes a problem. You simply adjust how the rotations are graded, weigh the shelf less and evals more. Maybe even create hours requirements or something. The options are endless, but suffice it to say schools can probably compel behavior on the wards better than they can in a p/f preclinical Setting.

Before that, they will probably start carving out dedicated time, likely by stealing some from the old S1 study period and adding it on the end of M3. I could carving 4 weeks off a 6 week S1 dedicated block and make it an S2 block later.

When I have clinical students with me, I just set expectations early and they always step up and meet them. They’re basically just there when I’m there doing anything meaningful, and I send them home whenever I wish I could be going home but still have notes to write and paperwork to do. I also tend to let them do quite a bit in the OR which most love, and I also expect them to prep for and scrub any cases I’m doing. I don’t ever send people home until the learning time is done.

I think some rotations are bad about setting expectations. Students show up, pre round, round, and then sit around while house staff execute the plans. Maybe there’s a didactic or something in there. Then they’re often ignored and not engaged unless something come up. Hard to blame them for using their time to study. It’s difficult to be engaged and interested when you’re being actively ignored until “oh hey there’s a cool case if anyone wants to see it…”

Don’t ask, just tell someone if it’s something they need to see and expect them to be there. It’s not rocket science.

 

[Esmolol]

Since clinicals are graded, schools can probably fix this if/when it becomes a problem. You simply adjust how the rotations are graded, weigh the shelf less and evals more.

This would accentuate the fact that grading often is random and depends on whom you get as your attending or what service you will be assigned to. For instance, during my surgery clerkship, some of my friends got the easiest line-up possible, plenty of study time, and high clinical grades... for just existing. Others were not so lucky and had to hustle for a grade in the "right where they should be" grade.

Maybe even create hours requirements or something.

This! I wish there was a strict and consistent time schedule, plenty clinical requirement also allowing for study time, say 6/7am-1/2pm. 2pm - you walk out no questions asked and go study.

When I have clinical students with me, I just set expectations early and they always step up and meet them. They’re basically just there when I’m there doing anything meaningful, and I send them home whenever I wish I could be going home but still have notes to write and paperwork to do. I also tend to let them do quite a bit in the OR which most love, and I also expect them to prep for and scrub any cases I’m doing. I don’t ever send people home until the learning time is done.

On behalf of your students - THANK YOU!

I think some rotations are bad about setting expectations. Students show up, pre round, round, and then sit around while house staff execute the plans. Maybe there’s a didactic or something in there. Then they’re often ignored and not engaged unless something come up. Hard to blame them for using their time to study. It’s difficult to be engaged and interested when you’re being actively ignored until “oh hey there’s a cool case if anyone wants to see it…”

Preach! "Ignorde until something cool comes up" or even better - "just ignored". So many times has this happened where we were left out of the loop on the events pertaining to patients we were following and "participating in their care". You go and present on rounds and it turns out that 20 minutes ago the resident got a call from their radiology resident friend that the patient has something acute and they should go to the OR. The resident knows because they got the call. The interns know because the resident told them because they need to put orders in etc. You don't know because there was no need to let you know and all of this happened while you were with other students and the attending in a different room and the resident stepped out to take the call. And then you're all surprised that all of this happened and the attending blames you because..... it's your patient and you should be the first to know things like that.

Don’t ask, just tell someone if it’s something they need to see and expect them to be there. It’s not rocket science.

Yes! Treat students like people not like garbage...

 

[Angus Avagadro]

Maybe because a good chunk of those hours are doing YOUR and the hospitals bitch work, allowing the hospital (and possibly you) to bill substantially more while they get paid trash? Not everything residents are tasked with is a learning experience/something you need an MD for. Yet the system is designed in a way that residents have the lowest negotiating power on the totem pole and thus have to deal with things other groups don't want to deal with. At my hospital they do social work, patient transport, etc.

You do realize that all the bitch work you describe is actually attending work, I was an Anesthesiologist. So setting up your own room, drawing up your own meds, seeing all of your consults the night before, sitting your own cases, writing post op notes is exactly what attendings do.

 

[VA Hopeful Dr]

You do realize that all the bitch work you describe is actually attending work, I was an Anesthesiologist. So setting up your own room, drawing up your own meds, seeing all of your consults the night before, sitting your own cases, writing post op notes is exactly what attendings do.

I think students and residents over estimate how they affect our work flow and don't truly understand how billing works...

 

[operaman]

I think students and residents over estimate how they affect our work flow and don't truly understand how billing works...

Yeah I hope the poster above who said something about that revisits his comments when he finishes training!

For me, a senior resident definitely makes me faster in clinic. One, because they’re more efficient. Two, because I dispense with the whole presentation thing with them. I just have them tell me their short one line assessment and their plan. I trust they can do the rest, plus I’m going to redo it anyhow. For a senior, learning to make the plan and talking through options is where the learning happens.

For interns/juniors and students, definitely a time suck. Mainly because they’re understandably inefficient, but also because I have them give more formal presentations. For them, it’s about taking a good history and doing a good focused exam. It’s about turning that into a concise presentation. So that always eats up time.

They definitely don’t help me bill more. I insist on doing my own notes because I’m very careful in what I write so I can justify my billing and the procedures I do. I do pretty insane volume and I can’t risk a shoddy student note screwing me over in an audit!

 

[Angus Avagadro]

Yeah I hope the poster above who said something about that revisits his comments when he finishes training!

For me, a senior resident definitely makes me faster in clinic. One, because they’re more efficient. Two, because I dispense with the whole presentation thing with them. I just have them tell me their short one line assessment and their plan. I trust they can do the rest, plus I’m going to redo it anyhow. For a senior, learning to make the plan and talking through options is where the learning happens.

For interns/juniors and students, definitely a time suck. Mainly because they’re understandably inefficient, but also because I have them give more formal presentations. For them, it’s about taking a good history and doing a good focused exam. It’s about turning that into a concise presentation. So that always eats up time.

They definitely don’t help me bill more. I insist on doing my own notes because I’m very careful in what I write so I can justify my billing and the procedures I do. I do pretty insane volume and I can’t risk a shoddy student note screwing me over in an audit!

Absolutely. What that poster doesn't yet understand is all that attending work needs to be done, key word...efficiently. If a newly hired physician can't produce the volume of RVUs required to cover the costs of their compensation package, then they won't be fired, but their employment contract will not be renewed, and all those restrictive covenants will be in place. My buddy was the ENT PD at our local uni, and even after 30 yrs, he was only offered a 1 yr contract annually.

 

[Just D.O. it]

I'm always fascinated by many students who believe if it is not going to help me get a higher board score, then it's a waste of their time. They obviously have forgotten why they want to become a physician. These students appear to want to be the physician I choose to take care of my Mother in Law.

While I understand this attitude from some old school attendings, I believe it to be kind of disingenuous. Ultimately when it comes time to apply for residency which can result in a complete change of career trajectories for students, a few extra percentiles on STEP can arguably be the best bang for your buck to have on your resume.

With regards to "they have forgotten why they want to be a physician", in all honesty they cannot worry about their idealistic goals when the very real threat of going unmatched is hanging over their heads. I don't mean any offense, but I'm sure most of those students have matching in their desired specialty/program as a higher priority than "being the kind of physician you'd want for your mother in law". Because quite frankly STEP has more power to determine their destiny than you do in many cases.

The reality is that many clinical professors nowadays are detached from the process and they don't realize that students arent properly rewarded for putting forth effort. There are stories posted on here time and time again of students who go the extra mile only to get the same cut and paste eval and rec letters as everyone else. STEP isn't like this, generally if you do the studying, and put forth the effort you get a score above your peers to show for it.

And just to address the other scenario, like I mentioned even if those students are rewarded with better evals or rec letters, they often still end up as secondary to their STEP in terms of weightage on their residency apps.

As cynical and/or defeatist as it may sound, in my mind this is not a case of fault on the students. It is a classic case of don't hate the players, hate the game.

edit: very much agree with the way @Billiam95 put it "this is simply students responding to incentives".

In my eyes its almost cruel to expect students to act differently unless the critic is making a good faith push to change the incentives. In the simplest sense med school is school, why would you expect students to divert time from something that is a huge portion of their grade as a residency applicant to something worth much less.

 

[RapidEyeMovementLearning]

Fact is that step 2 is more deciding of your future than a few evaluation comments. Don't feel obligated to see the placenta accreta case just because you were the odd one out... honestly do your own thing and forget any other students even exist on your service.

The key for 3rd year is just to seem engaged and interested... ask like one thoughtful question per day, stay out of the way, ask about their kids and vacation plans, remember the kids ages and ask about stuff like sports, graduations, college etc. Ask if they have physical journals mailed to the office or clinic that you can take home and read. Flatter them in every way you can. Just finished an H&P? Before giving the report to your attending mention how much the patient loves them. Then around 12-1pm you can pull out the question about leaving early to study. If you get an immediate response "Yeah sure go for it" with no eye contact or anything, just say thanks and gtfo. Once in a while ask if you can read about a certain topic when you get home, so that you can talk about it the next day. Something related to your patients from the day. If they ever deny your request to go home early to study, then never ask again and plan to stay the full time until you are finished with the rotation.

Bonus is that you'll make some truly deep and meaningful connections with your attendings that go beyond medicine talk, and you can get a spectacular LOR

If you do an H&P or scrub in for surgery on a patient, and then learn that patient will be returning for f/u while you are still on the rotation, just say you found the patient really interesting and ask if you can "follow" them (they love this from feedback I got)

You got to play the game otherwise you'll be left in the dust