(Serious) Why do 4th year students need supervision but midlevels don't?

[MedicineZ0Z]

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I honestly don't get this. A third year med student will have far more knowledge than a typical NP/PA. Only thing they lack is familiarity with the work setting.
So why are 4th year students supervised to such a degree yet midlevels can suddenly practice independently with a tiny fraction of the knowledge.

In more simple terms, why are students on rotations reduced to glorified shadowers when (far less competent) midlevels can go ahead and practice? The former carries so much liability risk for some reason yet the latter doesn't?

 

[Redpancreas]

This recent notion of experienced medical students being equals to PAs needs to stop. We are an uncooked product, while a PA has completed their professional training and now has a specific role. We may be more knowledgeable about medicine, but we are not ready from a practical standpoint to do what an experienced PA has been coached to do by supervising physicians. If it feeds anyone’s ego, know that we have to go slower to reach a higher peak.

In terms of glorified shadowing, it’s unfortunate and not right but it’s our own field specific problem. It’s not going to be fixed by pointing fingers at mid levels.

 

[Forever Geebs]

Until you can change the system, accept that the system exists for a reason and operate within its confines.

 

[MedicineZ0Z]

This recent notion of 4th year medical students being equal to PAs needs to stop. We are an uncooked product, while a PA is a completed professional with a specific role.

I wasn't suggesting them being "equals."

Medical competence isn't in a vacuum. It's a spectrum and when you're practicing medicine, your title isn't what runs patient care.

 

[MedicineZ0Z]

Until you can change the system, accept that the system exists for a reason and operate within its confines.

No reason we can't have a serious discussion on this topic.

 

[901251]

 

[Oso]

lol med students don’t have actual knowledge

 

[MedicineZ0Z]

lol med students don’t have actual knowledge

That's a whole different topic of discussion. Are you indirectly implying a fresh PA/NP has actual knowledge (despite 1/100th the training time)?

 

[Donald Juan]

Because I would trust the NP who has been in our clinic for the past 5 years well above any 3rd or 4th year med student with our regular patients. She may not know the translocations of every B-cell lymphoma or the biochemistry behind PKU, but she knows how our attendings like to practice and how to manage our bread and butter complaints, and most importantly when she needs to ask for help.

 

[Redpancreas]

I wasn't suggesting them being "equals."

Medical competence isn't in a vacuum. It's a spectrum and when you're practicing medicine, your title isn't what runs patient care.

Ok fine, you didn’t technically say that, but based on the way you present the two extremes it sounds like you’re asking why medical students don’t have autonomy and the answer is similar. One person has completed a degree with practical and theoretical training while MD/DO students are learning to transition from book smart to being useful in the hospital. That transition point varies for multiple people and I don’t think we should ask students do be making any unsupervised decisions at this point.

Again your point about glorified shadowing is valid in my opinion. Let me explain my thoughts about that a bit more. Looking at a medical school student/admin. All their focus is on students passing their MC exams and Step 1. After that, admin stops caring and students are thrown into a clinical setting where numerous entities are indirectly accountable for them and where learning is mostly passive. You can be aggressive and try to put a lot of effort in clinically but the way to do well in third year is to read and honor the shelves and be likable (not be competent) to receive evals. Summarized, there is no clinical competency assessed at all in medical school outside Step 2CS covering the bare minimum. Some students take it upon themselves to take more clinical responsibility than others but it’s completely self-directly. Then 4th year is a joke and the standards are to show up. Compare that to even nursing curriculum. Before interviewing patients, I sometimes see nursing rounds so I stop and watch in spite of myself. Their rounds on patients ware actually pretty educational from a practical standpoint. They have their head nurse sit and watch while the student starts present all the clinical information and are incredibly keyed into all the details. If they miss one detail, they’re marked down. It’s really a good thing to watch and something frankly some medical students who haven’t really clicked clinically need to see. If we miss even a critical thing like I/O on surgical patient or a foot exam on a new homeless diabetes admit, we’re just chided. Our grades don’t suffer and ultimately medical students are driven by grades. Once we get to residency, we are forced to pick up things very quickly as we get an active role. Until then, we are passive observers.

 

[901251]

Love these naive medical students who think their 2 years of didactic training should provide them autonomy. It’s actually quite cute.

 

[MedicineZ0Z]

Because I would trust the NP who has been in our clinic for the past 5 years well above any 3rd or 4th year med student with our regular patients. She may not know the translocations of every B-cell lymphoma or the biochemistry behind PKU, but she knows how our attendings like to practice and how to manage our bread and butter complaints, and most importantly when she needs to ask for help.

I'm more so comparing a fresh graduate NP/PA to a student. Even still, a student could spend 3 months in that clinic and make more detailed clinical decisions than the NP could.

Ok fine, you didn’t technically say that, but based on the way you present the two extremes it sounds like you’re asking why medical students don’t have autonomy and the answer is similar. One person has completed a degree with practical and theoretical training while MD/DOs are learning to transition from book smart to being useful in the hospital. That transition point varies for multiple people and I don’t think we should ask students do be making any unsupervised decisions at this point.

Again your point about glorified shadowing is valid in my opinion.

I'm not arguing for unsupervised students. I'm arguing for supervised midlevels 🙂

Also, what practical training has a midlevel completed that a 4th year student hasn't? The midlevel actually has significantlyyy less clinical hours. Hence it's mind boggling the midlevel can operate alone.

Love these naive medical students who think their 2 years of didactic training should provide them autonomy. It’s actually quite cute.

It absolutely shouldn't. Point is midlevels should not have autonomy.

 

[Oso]

That's a whole different topic of discussion. Are you indirectly implying a fresh PA/NP has actual knowledge (despite 1/100th the training time)?

I think you are confusing length of training with competence.

NP's/PA's are trained to do a specific job and are competent at doing that job.

Med students rotate through a bunch of different fields where the main objective is to learn random ****, some of it useful. Competence is developed with residency training.

What year are you in school?

 

[MedicineZ0Z]

I think you are confusing length of training with competence.

NP's/PA's are trained to do a specific job and are competent at doing that job.

Med students rotate through a bunch of different fields where the main objective is to learn random ****, some of it useful. Competence is developed with residency training.

What year are you in school?

Where are you getting this from? Have you actually seen what NP/PA clinical training is like? They learn what to do once actually hired for a real job.

 

[W19]

This recent notion of experienced medical students being equal to PAs needs to stop. We are an uncooked product, while a PA is a has completed their professional training with a specific role. We may be as knowledgeable about medicine, but we are not ready from a practical point to do what a PA does.

In terms of glorified shadowing, that’s unfortunate and not right.

The system should give US students who pass step1/step2(ck/cs) the option to practice as a PA if they decide not pursue residency...

 

[RNtoMD87]

No reason we can't have a serious discussion on this topic.

I'm not trying to be condescending or insulting, but I can tell that you've never worked in a healthcare field alongside residents and PA/NPs

 

[Oso]

Where are you getting this from? Have you actually seen what NP/PA clinical training is like? They learn what to do once actually hired for a real job.

Not really. I've been kinda busy focusing on my own training and not like, throwing fits about other types of providers.

Again, what year are you in med school?

 

[MedicineZ0Z]

I'm not trying to be condescending or insulting, but I can tell that you've never worked in a healthcare field alongside residents and PA/NPs

I've actually worked with both in more than one setting. Aside from that, also seen new graduate midlevels in action and midlevel students.

 

[RNtoMD87]

That's a whole different topic of discussion. Are you indirectly implying a fresh PA/NP has actual knowledge (despite 1/100th the training time)?

As much as I aspire to be an MD and do not like the way NPs are going, I trust an NP with 5-25 years of RN experience a lot over a resident that may not have but a couple years practical experience.

 

[W19]

Because I would trust the NP who has been in our clinic for the past 5 years well above any 3rd or 4th year med student with our regular patients. She may not know the translocations of every B-cell lymphoma or the biochemistry behind PKU, but she knows how our attendings like to practice and how to manage our bread and butter complaints, and most importantly when she needs to ask for help.

The problem is that there are new NP out there as well...

 

[RNtoMD87]

The problem is that there are new NP out there as well...

Most schools I know of require a minimum of 2-3 years RN experience and I'm sure some complete only the minimum, but out of all of the RNs I know going to NP school (and I know quite a few. Probably in the neighborhood of a dozen), the least experience I know of is 5 years, and my best friend is graduating with his NP this May with 12 years RN experience.

 

[Treebeard]

NPs and PAs have obtained a license to perform a particular job.

Medical students have not done so.

Next.

 

[RNtoMD87]

The problem is that there are new NP out there as well...

If there is ONE complaint I do have about many residents, its the fear or complete aversion to ask for help. I think that's gotta be number one.

 

[W19]

Ok fine, you didn’t technically say that, but based on the way you present the two extremes it sounds like you’re asking why medical students don’t have autonomy and the answer is similar. One person has completed a degree with practical and theoretical training while MD/DO students are learning to transition from book smart to being useful in the hospital. That transition point varies for multiple people and I don’t think we should ask students do be making any unsupervised decisions at this point.

Again your point about glorified shadowing is valid in my opinion. Let me explain my thoughts about that a bit more. Looking at a medical school student/admin. All their focus is on students passing their MC exams and Step 1. After that, admin stops caring and students are thrown into a clinical setting where numerous entities are indirectly accountable for them and where learning is mostly passive. You can be aggressive and try to put a lot of effort in clinically but the way to do well in third year is to read and honor the shelves and be likable (not be competent) to receive evals. Summarized, there is no clinical competency assessed at all in medical school outside Step 2CS covering the bare minimum. Some students take it upon themselves to take more clinical responsibility than others but it’s completely self-directly. Then 4th year is a joke and the standards are to show up. Compare that to even nursing curriculum. Before interviewing patients, I sometimes see nursing rounds so I stop and watch in spite of myself. Their rounds on patients ware actually pretty educational from a practical standpoint. They have their head nurse sit and watch while the student starts present all the clinical information and are incredibly keyed into all the details. If they miss one detail, they’re marked down. It’s really a good thing to watch and something frankly some medical students who haven’t really clicked clinically need to see. If we miss even a critical thing like I/O on surgical patient or a foot exam on a new homeless diabetes admit, we’re just chided. Our grades don’t suffer and ultimately medical students are driven by grades. Once we get to residency, we are forced to pick up things very quickly as we get an active role. Until then, we are passive observers.

I think you are giving nurses too much credit... And I was one.

 

[DexterMorganSK]

The simple answer is that the NP/PA have completed their training and had a license to work, whereas, you as a student, do not, thus the need for supervision.

 

[RNtoMD87]

NPs and PAs have obtained a license to perform a particular job.

Medical students have not done so.

Next.

I think this is THE reason. Liability. As a resident you're probably practicing under someone else's license.

 

[MedicineZ0Z]

NPs and PAs have obtained a license to perform a particular job.

Medical students have not done so.

Next.

The simple answer is that the NP/PA have completed their training and had a license to work, whereas, you as a student, do not, thus the need for supervision.

Even when that job includes independent practice with 0 supervision.

The point is that it's ridiculous midlevels can operate alone. Not that students should be able to do so.

 

[DocFluffy]

Because NP/PA have a licence and passed their boards to practice and 3rd/4th year med students have no licence to practice. As an MD/DO, you are bounded by the rules set forth by your accrediting body which states when in your training you can be unsupervised. Until then, tough luck.

 

[RNtoMD87]

I think you are giving nurses too much credit... And I was one.

Both are full of individuals. I have seen residents that I was so thoroughly impressed with that I made time to write a long letter to hospital administration about their skill and compassion. I have also told residents to leave my patient alone and call the attending before, and feared that they would kill someone. Same for nurses. We have several nurses I would trust my life to. And some that scare me.

 

[DexterMorganSK]

Even when that job includes independent practice with 0 supervision.

The point is that it's ridiculous midlevels can operate alone. Not that students should be able to do so.

They need supervision here in NY hospitals, if not directly then indirectly.
Have an ER-PA friend and they have to get their MD consent for specific tests and have to go over everything with them for all patients they saw.

 

[RNtoMD87]

Even when that job includes independent practice with 0 supervision.

The point is that it's ridiculous midlevels can operate alone. Not that students should be able to do so.

In my state NPs cannot practice independently, they must have an MD sign off on them. But I agree, like I said, I have a big problem with the direction NPs and PAs are going.

 

[Donald Juan]

The problem is that there are new NP out there as well...

I agree that a new NP should not be able to practice independently

 

[MedicineZ0Z]

In my state NPs cannot practice independently, they must have an MD sign off on them. But I agree, like I said, I have a big problem with the direction NPs and PAs are going.

And in many states (growing number) they practice alone. My point is that someone with far less knowledge than a med student is suddenly practicing alone without supervision.

 

[Redpancreas]

I think you are giving nurses too much credit... And I was one.

Well, I can’t argue with your experience but just based on my experience, nurses are held to higher standards and penalties than a medical student in terms of what they are clinically accountable. Nursing students are expected to report patient findings, interpret them superficially, and move forward. Their ability to do this is then measured pretty accurately. For medical students, as I said before we have these rubrics that say things like “this student surpassed all expectations and was a sharp interpreter, contemplative interpreter, active manager, and passionate educator but in reality the resident just liked you and checked off a box and you spent most time studying for your shelf. For an RN v. a medical student on average, I would say their reporting is better than ours and they know indications without the burden of the reasoning which makes them useful at noticing things and doing things given their experience.

 

[MedicineZ0Z]

Well, I can’t argue with your experience but just based on my experience, nurses are held to higher standards and penalties. For an RN v. a medical student on average, I would say their reporting is better than ours and they know indications without learning reasoning or mechanisms which makes them useful at noticing things and doing things given their experience.

lol. If I had a dollar for every time an RN asked a question or showed lack of confidence about something basic...
You wouldn't ever find a resident who doesn't know any of the long list of basics. But you'll find a *ton* of RNs and a very high number of NPs/PAs. That's the core fundamental difference. It's the consistency across one profession and the lack of across the others.

 

[W19]

And in many states (growing number) they practice alone. My point is that someone with far less knowledge than a med student is suddenly practicing alone without supervision.

You have valid point... The bottom line is they are practicing medicine with far less knowledge than a 3rd/4th year med student.

The fact is medicine is f-up... You will find people here people that are ok with NP practicing medicine (yes they are practicing medicine) and yet the same people would say someone who completed an intern year is not equip to do what NP do. We are brainwashed!

 

[MedicineZ0Z]

You have valid point... The bottom line is they are practicing medicine with far less knowledge than a 3rd/4th year med student.

The fact is medicine if f-up... You will find people here that are ok for NP to practice medicine (yes they are practicing medicine) and yet the same people would say someone who completed an intern year is not equip to do what NP do. We are brainwashed!

Exactly.
Most of these people have no idea the type of "training" midlevels get yet continue to be a sellout for our profession.

 

[W19]

Well, I can’t argue with your experience but just based on my experience, nurses are held to higher standards and penalties. For an RN v. a medical student on average, I would say their reporting is better than ours and they know indications without the burden of the reasoning which makes them useful at noticing things and doing things given their experience.

I guess the nurses you interact with come from Heaven School of Nursing... I am going to give you an example of what a nursing student asked me: She had a procalc problem of that sort. A vial of 8ml has 3 mg of morphine, and if we want to give the patient 1 mg of morphine, how many ml should we give that patient... She asked to solve that for her. She is a freaking charge nurse now.

 

[Redpancreas]

I guess the nurses you interact with come for Heaven School of Nursing... I am going to give you an example of what a nursing student asked me: She had a procalc problem of that sort. A vial of 8ml has 3 mg of morphine, and if we want to give the patient 1 mg of morphine, how many ml should we give that patient... She is a freaking charge nurse now.

Mhm, troublesome and I could see that. Yeah I tutored them in undergrad and logical things like gen chem stoich was a very foreign concept to most of them and it doesn’t help to say some nurses know their stuff because as someone said, there’s no med student that wouldn’t know that.

 

[RNtoMD87]

lol. If I had a dollar for every time an RN asked a question or showed lack of confidence about something basic...
You wouldn't ever find a resident who doesn't know any of the long list of basics. But you'll find a *ton* of RNs and a very high number of NPs/PAs. That's the core fundamental difference. It's the consistency across one profession and the lack of across the others.

I think you give some residents too much credit. I've had a lot of residents give me confused looks over things that even new nurses find very basic. Different but overlapping fields.


-Pulmonology resident looked at me like I had a dck on my forehead when after inserting a catheter and after removing it several times the patient always had serious urine retention problems requiring another catheterization, that I said "Well are we not doing bladder training?" When I explained it she went "OH! yeah! Good idea! Do that!"

-I've had an OMFS resident insist that we draw a THIRD blood gas on a patient that frequently plugged and was in obvious respiratory distress because "I don't know if I trust that pulse ox sensor reading" (Other 2 blood gases showed it was consistent, but hey lets do a third!"


These are just two recent examples. Moral of the story, every time you have an MD being astounded at what a ***** an RN is, we feel the same about a resident, and at times attendings. There are *****s in every field, and were ALL stupid sometimes. And yes, there are a lot of stupid RNs. I really feel like instead of teaching a bunch of useless crap like art electives and sociology, they need to teach more science. In school, anytime myself or my friend Daniel asked an anatomy or pharm question that had any depth, many other students and the instructors acted annoyed. But I need to know the in depth of why to do something. I noticed generally speaking there were differences in our male brains and the female brains. They were better at emotional reasoning and subjective stuff, and we for the most part crushed pharm and anatomy.

 

[RNtoMD87]

I guess the nurses you interact with come from Heaven School of Nursing... I am going to give you an example of what a nursing student asked me: She had a procalc problem of that sort. A vial of 8ml has 3 mg of morphine, and if we want to give the patient 1 mg of morphine, how many ml should we give that patient... She asked to solve that for her. She is a freaking charge nurse now.

Yeah that's pretty scary. Honestly nursing math always made me chuckle. I never "studied" math for nursing. Infact its rare that its something you cant do in your head.

 

[W19]

Mhm, troublesome.

I tutored these people so I can tell you that nursing is a profession that has people with a wide range of IQ...

 

[niko327]

The system should give US students who pass step1/step2(ck/cs) the option to practice as a PA if they decide not pursue residency...

Yes, If you have these exams done and the core rotations and shelf exams finished, I think that is a perfectly fine idea.

 

[W19]

Yeah that's pretty scary. Honestly nursing math always made me chuckle. I never "studied" math for nursing. Infact its rare that its something you cant do in your head.

Since you are a nurse, so I am sure you know this is not atypical...

 

[MedicineZ0Z]

I guess the nurses you interact with come from Heaven School of Nursing... I am going to give you an example of what a nursing student asked me: She had a procalc problem of that sort. A vial of 8ml has 3 mg of morphine, and if we want to give the patient 1 mg of morphine, how many ml should we give that patient... She asked to solve that for her. She is a freaking charge nurse now.

Seen endless examples like this, but more often involving clinical knowledge.

I think you give some residents too much credit. I've had a lot of residents give me confused looks over things that even new nurses find very basic. Different but overlapping fields.

How about some examples? Nursing is its own scope. We don't like when nurses (NPs) try to come onto the scope of medicine.

 

[RNtoMD87]

Since you are a nurse, so I am sure you know this is not atypical...

I haven't seen it a lot practicing, but in school it astounded me that people stressed over such stupidly simple math.

 

[niko327]

I honestly don't get this. A third year med student will have far more knowledge than a typical NP/PA. Only thing they lack is familiarity with the work setting.
So why are 4th year students supervised to such a degree yet midlevels can suddenly practice independently with a tiny fraction of the knowledge.

In more simple terms, why are students on rotations reduced to glorified shadowers when (far less competent) midlevels can go ahead and practice? The former carries so much liability risk for some reason yet the latter doesn't?

New PAs just out of school are watched like a hawk for their first few years. I embraced this with wide open arms when I first finished. We were not really as autonomous as you might think during this time. Experienced PAs are given the appropriate amount of latitude commensurate with their experience, sometimes that latitude is great, but make no mistake, it is earned. This system mostly regulates itself. The reason a 3rd or 4th year medical student is not given the autonomy is the same reason a PA with 1 or 2 years of experience is not given real autonomy, all the seriously sick patients would be dead meat.

 

[Redpancreas]

I'm more so comparing a fresh graduate NP/PA to a student. Even still, a student could spend 3 months in that clinic and make more detailed clinical decisions than the NP could.

I'm not arguing for unsupervised students. I'm arguing for supervised midlevels 🙂

Also, what practical training has a midlevel completed that a 4th year student hasn't? The midlevel actually has significantlyyy less clinical hours. Hence it's mind boggling the midlevel can operate alone.



It absolutely shouldn't. Point is midlevels should not have autonomy.

Doesn’t an NP have to have worked as a nurse for X number of years? Also simply to get into nursing school, isn’t there a bare minimum of hours where they have work NA jobs where they learn how to do things like fill vials (hence learn to divide 8/3), etc? I also felt PAs had a similar robust clinical requirement.

 

[W19]

I haven't seen it a lot practicing, but in school it astounded me that people stressed over such stupidly simple math.

If they stressed over it, that tells you everything... I encountered that when I was getting my nursing degree and I also used to tutor a lot of CNA who were going to LPN/RN school.

That might sound strange, but it's one of the reasons I got out of nursing

 

[RNtoMD87]

Seen endless examples like this, but more often involving clinical knowledge.

How about some examples? Nursing is its own scope. We don't like when nurses (NPs) try to come onto the scope of medicine.

Well generally on my floor, we don't think highly of our OMFS residents in general... Patients get butchered, become disfigured, lots of lawsuits, etc.

Now our ENT residents are seen as pretty awesome. They take on many of the same times of patients as OMFS and in our opinion do a much better job. But our HMS residents, are overall seen as not so good. Its concerning, because these residents are of the school Id want to attend due to proximity, and that it is thought of by the doctors ive spoken to as superior to other state schools. My cousins wife is an HMS resident and she agrees. She said the ENT residents spend a lot more time in the hospital though.