Teaching med students in the private world

[TexasPhysician]

---

Members don't see this ad.

I’ve had a medical school approach me about having 1 medical student rotate through my cash private practice. It would be a slow transition with year 1 being 1 student for about 3 weeks. 3 weeks break between students.

Part of me thinks that I could utilize med students to get some history on new evals (save some time) and fit in urgent appointments more easily with the student updating me with long winded urgent patients. I could also see that some patients would not want a student involved. If I offered a discount for shorter appointments with me that involve more time with a med student, I’d definitely have some takers. Having an academic affiliation has some additional benefits.

Has anyone done this in a cash practice? Worth it to you?

 

[Monocles]

Isn't there a saying that the BEST medical students would only slow you down by double the amount of time? 😛

 

[TexasPhysician]

Isn't there a saying that the BEST medical students would only slow you down by double the amount of time? 😛

That would not fly. They would need to learn quick.

 

[Ironspy]

Not sure it would save any time if you only get them for 3 weeks as it’ll take a week (At least) to train them. Also MS quality and interest in psych varies and could dilute your brand for new patients.

established patients presenting for urgent visits seeing a supervised MS3 could work better imo

 

[Horners]

If you can work it out to get 4th year medical students who are interested in psych to come. Its worth it, otherwise your expectations of what a 3rd year will be able to do will leave you very frustrated.

 

[Merovinge]

Quality of the med school would definitely have an impact on my decision for this. If a strong program was trying to give a unique MS3/4 experience I would consider it, otherwise medicore to bad med students on a required rotation for M3 year would be a hard pass for me.

 

[nighthawk2551]

If you're solely looking into it to increase your productivity you probably shouldn't take a student on anyways. Having a med student should be about teaching, not making more money.

 

[Bartelby]

I agree with Horners and Merovinge, an MS4 who chooses to rotate with you because they have an interest in psychiatry will be quite different from an MS3 who is required to be there. I agree with other posters, though, that even a very good MS4 will mainly slow you down. You have to decide if the hit in productivity is worth it to get that teaching exposure. You should also consider your population's openness to seeing a student, many cash patients would probably be unhappy with that.

On the other side, though, teaching and being connected with an academic medical center is pretty fun! if I were in your position I would give it a try and see if there's a way you can make it work, but be aware you're going to be adding to your workload rather than reducing it.

 

[Merely]

I think this is a bad idea as students are very inefficient and don’t know what the hell is going on a lot of the time (even the decent ones) especially in a cash only practice where the patients expect a service that is worth their money and not want to see a student fumbling through his questions

 

[Sushirolls]

I have taken many students over the years.
Do it because you want to give back.
Assume you will be slower and less efficient.
I will also block out a few hours to do didactic lecture like teaching one on one with power points or other templates to cover the topics.
Some schools will pay a few bucks, that might offset things a little, but odds are you will still lose out financially.
Simply put its a pay it forward mentality you will need to have.

 

[whopper]

I'm lukewarm against teaching in private practice unless you just have all the free time in the world to teach.

In private practice you don't see many of the moderate to severe symptoms. E.g. you don't get florid psychosis much if at all.
Of course in private practice you get the occasional psychotic patient whose psychosis is mild but that person's presentation if anything is often times highly muted.

In PP, another problem is it's a heck of a lot more boring than ER or inpatient. Pt after pt after pt where you're not seeing gross signs of mental illness, most patients are doing relatively well, and the student doesn't have many opportunities to get a brand new patient, do an intake, and report it to the attending. In inpatient or ER students often times have to move around, their adrenaline is up because they know some of the patients could be dangerous, they play a very active role in talking to patients, while in the office they are usually backseat and merely being an audience without anywhere near as much participation.

I agree with paying it forward (spent 4 years working in a state hospital, 7 years as a university professor making much less than I would in private practice cause of this exact reason), but private practice is a poor venue for teaching.

I miss teaching. Reason why I don't do it now is cause of the 2 medschools in the area, one I couldn't tolerate the incompetence, the other is pretty much so research heavy I'd have to be doing research as the main thing and I don't feel like doing that, on top of my income being cut in half while working much more. I miss inpatient and while I could do 1/2 inpatient, 1/2 outpatient my rent and most of my expenses for my office won't be changed by me working 1/2 time in the hospital, so it's not cost effective.

I've had students see me in PP. What I typically would have them do to make theirs, the patient's and my time better utilized is ask the patient to show up about 1 hour early and the student would do an intake, report it to me then I'd do it again but this time having to spend much less time on the standard questions and more time actually talking to the patient one-on-one getting to better know them personally, but patients have to be warned to show up much more ahead of time, be willing to participate, and some frankly didn't want to be seen by a student.

 

[Celexa]

That would not fly. They would need to learn quick.

Nothing you have written makes you taking medical students sound like a good idea. The best medical students can somewhat make themselves useful in an inpatient setting. In outpatient settings it's harder--I always felt I was impeding workflow (and it was invariably true), it takes time to teach that takes you away from your patients. MOST of the students you'll get assigned, if this school wants your practice as part of their core rotations, will be either inexperienced M3s, students not planning to do psychiatry, or both. The best, quickest leaning med students will still be coming to you not knowing 95% of what they need to do in a psychiatric encounter.

Please don't take this on if you think it will in any way help your efficiency. Only do it if you understand you will sacrifice time and efficiency to provide any type of educational experience, and bigger sacrifice to provide a GOOD educational experience.

 

[Liquid8]

When I was in my first year out having final medical students in their pre-intern year rotations could be very helpful as they could do a lot of the ward tasks with relatively little supervision, but it depends on their interest/work ethic etc. Can recall one of my friends had a bad one who would say he’d do things but not actually deliver, so she ended up having to check everything herself.

In psychiatry I have found having medical students around slows me down quite a lot, so I wouldn’t count on any sort of productivity increase from having them around. The uninterested ones usually come up with some excuse to leave which often suited me fine.

At the start they’re probably only going to be able to observe how you interview and you’ll have to leave time for questions and explanations whether you do it during the interview or afterwards. The GPs I know who take on students usually book in less patients per hour (eg. 3-4 down from 5-6) and while they receive a small amount of compensation which doesn’t fully cover the cost of the patients missed, they all enjoy teaching which I think is the only reason one should be taking on medical students.

Was offered the opportunity to supervise psychiatry trainees, but at the time I was building up my own private practice and all the supervisions requirements would come out of my own time so I declined. However, I still find myself providing some informal mentorship/debriefing for the ones who rotate through our private hospital.

 

[Splenda88]

Why don't you hire a psych NP if you are looking to make $$$? Hiring a med student to increase your productivity is a bad idea. That might fly in primary care, but not in a cash practice specialty like psych.

 

[Merely]

Why don't you hire a psych NP if you are looking to make $$$? Hiring a med student to increase your productivity is a bad idea. That might fly in primary care, but not in a cash practice specialty like psych.

This is a horrible idea

 

[Splenda88]

This is a horrible idea

Not a big fan of NP, but if OP is trying to increase his bottom line, I think that's the way to go.

 

[TexasPhysician]

Why don't you hire a psych NP if you are looking to make $$$? Hiring a med student to increase your productivity is a bad idea. That might fly in primary care, but not in a cash practice specialty like psych.

That is the opposite of what I’m looking for. There are many positives to the academic affiliation including my enjoyment of teaching.

I understand that teaching itself will slow me down at times. I’m trying to see if there are ways that the student could periodically be helpful to recoup time elsewhere.

I’m hoping that even MS3’s could obtain cc, past med/psych, allergies, current meds, social hx, etc. After a little shadowing, helping me get through periodic urgent follow-ups would be nice. Maybe essentially acting as a scribe at times. Surely they can be functional somewhere/somehow.

I would plan to come in early for teaching on a daily basis. Periodic brief discussions during the day. I’d just rather not have to cut patient slots or stay later each day. If I can figure that out then I may do this. Otherwise I’ll likely pass.

 

[Merely]

That is the opposite of what I’m looking for. There are many positives to the academic affiliation including my enjoyment of teaching.

I understand that teaching itself will slow me down at times. I’m trying to see if there are ways that the student could periodically be helpful to recoup time elsewhere.

I’m hoping that even MS3’s could obtain cc, past med/psych, allergies, current meds, social hx, etc. After a little shadowing, helping me get through periodic urgent follow-ups would be nice. Maybe essentially acting as a scribe at times. Surely they can be functional somewhere/somehow.

I would plan to come in early for teaching on a daily basis. Periodic brief discussions during the day. I’d just rather not have to cut patient slots or stay later each day. If I can figure that out then I may do this. Otherwise I’ll likely pass.

I think if you have them essentially shadow you as a scribe and they have good hand writing, it certainly could be useful since then you don’t have to write anything and can fully engage the patient

 

[Celexa]

I think if you have them essentially shadow you as a scribe and they have good hand writing, it certainly could be useful since then you don’t have to write anything and can fully engage the patient

Medical students are not scribes! If you go over to the EM forum they have lots of debates over how to use scribes well and those are scribes they get to train and keep with them in one setting for an extensive period of time. Most medical students have abysmal note writing skills and they aren't going to get to an acceptable standard in the period of one rotation (2-4 weeks, minus some half days for didactics and the shelf).

It's completely unrealistic to think you can teach and keep the same number of patient slots per day. Taking on M3s with the idea of increasing efficiency is so obviously implausible it rises to the level of farce.

Also, at the institutions I've been at for medical school and residency a physician so blatantly trying to use a medical student as an unpayed employee would rapidly find themselves no longer a teaching site, although these were fairly privileged institutions that have their pick of teaching locations. Other schools are not able to be as choosy.

 

[MedMan80]

OP if you are considering a medical student, think of an IMG or FMG. Not only will you help a potential future physician obtain a residency spot, but you will find that many of them are very intelligent and motivated to do well. Not only this, you may also get a nice little stipend for letting them rotate with you!

 

[TexasPhysician]

OP if you are considering a medical student, think of an IMG or FMG. Not only will you help a potential future physician obtain a residency spot, but you will find that many of them are very intelligent and motivated to do well. Not only this, you may also get a nice little stipend for letting them rotate with you!

Interesting idea. Who do you contact about that?

 

[Crayola227]

That is the opposite of what I’m looking for. There are many positives to the academic affiliation including my enjoyment of teaching.

I understand that teaching itself will slow me down at times. I’m trying to see if there are ways that the student could periodically be helpful to recoup time elsewhere.

I’m hoping that even MS3’s could obtain cc, past med/psych, allergies, current meds, social hx, etc. After a little shadowing, helping me get through periodic urgent follow-ups would be nice. Maybe essentially acting as a scribe at times. Surely they can be functional somewhere/somehow.

I would plan to come in early for teaching on a daily basis. Periodic brief discussions during the day. I’d just rather not have to cut patient slots or stay later each day. If I can figure that out then I may do this. Otherwise I’ll likely pass.

I will point out that to my knowledge, most med schools, at least formally, forbid students being used to act as scribes.

There's a lot of things I feel was suboptimal in my own med school experience, and not only do I second that taking on med students should come from a purely altruistic place of giving without much expectation of getting in return (besides respect, gratitude, and effort), that it is such a disservice to use them as scribes, that it makes me emotionally angry to hear an attending propose it as a way to help themselves. You can tell yourself it is educational, but I think it's exploiting them in that it is a subpar clinical experience for them, and it seems that quite a few medical schools agree with this stance.

Most of these students are taking on $50K a year for their educational experience that is meant to be the building block of their entire career, and believe me, as much as people say subpar clinical skills gained during this time will be made up for in residency, I don't believe that is always the case, and in any case it sets the student up for significantly more painful intern year on top of what is already a most difficult time. I can't remember the breakdown of how much the students are paying literally by the minute, but it could be calculated. Nevermind when you add in interest.

I appreciate that you want to teach, and want students to help you in order to hopefully free up more of your time for quality teaching. Don't have them scribe.

It's part of the oath of Geneva and the Hippocratic oath to pass on what we have learned. It's not for money or saved time. It's the sacred duty of a professional, not a compensated job.

 

[Crayola227]

OP if you are considering a medical student, think of an IMG or FMG. Not only will you help a potential future physician obtain a residency spot, but you will find that many of them are very intelligent and motivated to do well. Not only this, you may also get a nice little stipend for letting them rotate with you!

There are issues with malpractice as far as what they are allowed to actually do. Most of the time, they just essentially shadow. I agree that if you write them a good LOR, then this is the best way to help oneself as far as time and money, yet still be helping. If you take some time to teach and try to get them as hands on as you can manage, so much the better.

 

[TexasPhysician]

I will point out that to my knowledge, most med schools, at least formally, forbid students being used to act as scribes.

There's a lot of things I feel was suboptimal in my own med school experience, and not only do I second that taking on med students should come from a purely altruistic place of giving without much expectation of getting in return (besides respect, gratitude, and effort), that it is such a disservice to use them as scribes, that it makes me emotionally angry to hear an attending propose it as a way to help themselves. You can tell yourself it is educational, but I think it's exploiting them in that it is a subpar clinical experience for them, and it seems that quite a few medical schools agree with this stance.

Most of these students are taking on $50K a year for their educational experience that is meant to be the building block of their entire career, and believe me, as much as people say subpar clinical skills gained during this time will be made up for in residency, I don't believe that is always the case, and in any case it sets the student up for significantly more painful intern year on top of what is already a most difficult time. I can't remember the breakdown of how much the students are paying literally by the minute, but it could be calculated. Nevermind when you add in interest.

I appreciate that you want to teach, and want students to help you in order to hopefully free up more of your time for quality teaching. Don't have them scribe.

It's part of the oath of Geneva and the Hippocratic oath to pass on what we have learned. It's not for money or saved time. It's the sacred duty of a professional, not a compensated job.

Scribing is essentially writing a clinical note during an evaluation in psychiatry. I wrote hundreds of notes as a medical student that was incorporated into the medical record. It’s incredibly educational and necessary. I’d have loved for my attendings to review my notes with me as a medical student.

 

[jurassicpark]

I’ve had a medical school approach me about having 1 medical student rotate through my cash private practice. It would be a slow transition with year 1 being 1 student for about 3 weeks. 3 weeks break between students.

Part of me thinks that I could utilize med students to get some history on new evals (save some time) and fit in urgent appointments more easily with the student updating me with long winded urgent patients. I could also see that some patients would not want a student involved. If I offered a discount for shorter appointments with me that involve more time with a med student, I’d definitely have some takers. Having an academic affiliation has some additional benefits.

Has anyone done this in a cash practice? Worth it to you?

I take medical students as a hospitalist. The hospital is working on several academic minded ventures and have thus encouraged me to do so. Plus the university is also throwing in a fancy Associate Prof title for me so my parents will finally believe I'm a real doctor.

Having a student or two can be fun. They're like eager little puppies. It also makes you a better doctor in some ways. A lot of the pathology and nitty gritty stuff you've long forgotten you have to re-learn as well, they'll also help you with looking up any new guidelines and updates.

I send them in to see a consult first as it allows several things:
- Allows me finish up what I'm doing
- Makes the patient happy they're seeing someone fast instead of waiting
- ROS ROS ROS!!

The downside of having students of course is yes they do slow you down a bit as you explain what you're doing. Also, you have to take time to teach time formally too. Just shadowing doesn't help them, they have to actively learn and not just passive, including delivering lectures.

 

[NickNaylor]

I agree that it seems like an MS4 would be ideal for a couple of reasons. First, they'll be more experienced and likely better able to operate in your practice. Can you imagine having a medical student who has zero experience coming to rotate with you? Yikes. Second, I agree with @whopper in that I don't think a private practice is the best environment for a student to learn about psychiatry. This is doubly true for someone who's only exposure to psychiatry may be their psychiatry clerkship. If you limit the pool to MS4s who will presumably be doing this as an elective, I would think you'd be more likely to have students going into psychiatry or students that are particularly interested in psychiatry. Having either group rotate with you would be valuable for different reasons; in the first case, they get exposure to private practice work (which they may get limited exposure to during residency depending on their program), and in the second case, they're more likely to patients as they are "in the real world" which may be helpful for those that end up in fields like IM, FM, OB/GYN, etc. (which I imagine would be the fields the bulk of those students would be going into - it's difficult for me to imagine a to-be surgeon, dermatologist, pathologist, etc. electively rotating on psychiatry).

I love teaching as well, but don't forget that working with medical students can be a beat down.

 

[Celexa]

Scribing is essentially writing a clinical note during an evaluation in psychiatry. I wrote hundreds of notes as a medical student that was incorporated into the medical record. It’s incredibly educational and necessary. I’d have loved for my attendings to review my notes with me as a medical student.

I agree that medical students should write notes. As a resident working with medical students I have my students write notes and then review with them in detail. It's an important part of learning. That is not scribing. They need as much time away from the patient working on their note as we spend interviewing, sometimes more. They cannot produce notes in real time because they cannot synthesize the relevant information in real time. Three weeks with you is not going to be enough time to turn them into a useful scribe, and you'll be starting over with each one. And that's without even getting into the fact that if they're attempting to scribe you won't be directly observing their interview skills, probably the single most important thing they should be learning and getting feedback on in a psych rotation.

You sound pretty set at this point so I don't expect to change your mind, but I feel very sorry for the med students it seems inevitable you're going to get.

 

[Merely]

I agree that medical students should write notes. As a resident working with medical students I have my students write notes and then review with them in detail. It's an important part of learning. That is not scribing. They need as much time away from the patient working on their note as we spend interviewing, sometimes more. They cannot produce notes in real time because they cannot synthesize the relevant information in real time. Three weeks with you is not going to be enough time to turn them into a useful scribe, and you'll be starting over with each one. And that's without even getting into the fact that if they're attempting to scribe you won't be directly observing their interview skills, probably the single most important thing they should be learning and getting feedback on in a psych rotation.

You sound pretty set at this point so I don't expect to change your mind, but I feel very sorry for the med students it seems inevitable you're going to get.

Lol calm down bro he will give his students a good experience scribing is not that bad

 

[splik]

OP if you are considering a medical student, think of an IMG or FMG. Not only will you help a potential future physician obtain a residency spot, but you will find that many of them are very intelligent and motivated to do well. Not only this, you may also get a nice little stipend for letting them rotate with you!

I have IMGs rotate with me (I do not charge as it is ethically questionable to do so if I am going to write them a letter but it would be reasonable to charge certain costs - e.g. application fees as an institution. Any stipend through an agency will not be worth it for the money). As they have graduated, they cannot be in the student role. They need to be supervised by a member of staff at all times and cannot be with patients alone. We require them to complete the HIPAA, child abuse reporting trainings/disclosures, and sign a liability waiver, and they must provide copies of their CV, medical school diploma, ECFMG certificate, USMLE transcript, and 2 LoRs from US physicians. We need a criminal background check also. They get to interview patients, write notes, present patients, gather collateral, propose management plans etc and get teaching and feedback. Like with med students, it can be a mixed bag, even though we are highly selective in the IMGs we have. It usually creates more work for me, not less.

 

[TexasPhysician]

I agree that medical students should write notes. As a resident working with medical students I have my students write notes and then review with them in detail. It's an important part of learning. That is not scribing. They need as much time away from the patient working on their note as we spend interviewing, sometimes more. They cannot produce notes in real time because they cannot synthesize the relevant information in real time. Three weeks with you is not going to be enough time to turn them into a useful scribe, and you'll be starting over with each one. And that's without even getting into the fact that if they're attempting to scribe you won't be directly observing their interview skills, probably the single most important thing they should be learning and getting feedback on in a psych rotation.

You sound pretty set at this point so I don't expect to change your mind, but I feel very sorry for the med students it seems inevitable you're going to get.

That’s a lot of assumptions that are far from accurate.

The medical school in question has already determined that adding community rotations is happening. They won’t fund further dedicated faculty, and they feel that varied real world experience is best. Students will rotate with the community and academic sites.

I can decline and may. The students will either join nearby clinics which may involve teaching by a PA along with some outdated psychiatrists or they will overcrowd existing sites. These options are disappointing to me, but that’s a debate for another day. I know the other options.

I think I’m pretty good at teaching and enjoy it, but I’m not at the stage in life where Im wiling to cut clinical hours yet.

If I can plan a formula where everyone wins, I’ll do it. If not, I’ll pass. My idea of winning is just getting through clinic hours in the same time frame without care suffering. The teaching hours will be provided.

I’m open to constructive criticism on how to better the experience or make this work. I’m even fine with advising that I pass as it may hurt my reputation as high quality cash only anyway.

 

[MedMan80]

Interesting idea. Who do you contact about that?

I'd reach out to the clinical departments of the big schools, as Texas has requirements on who can rotate there. The big ones are AUC, ROSS, SABA, St. Georges U. To address the malpractice concerns, we were covered for clinical rotations and paid for malprac, if you are taking on an observer, these students are typically not covered by malpractice and certainly there's a greater risk of issues down the line if you let them do any meaningful clinical work. If you stick to MS4, you should be getting some highly motivated students that can help your productivity.

 

[Orgone]

I’m even fine with advising that I pass as it may hurt my reputation as high quality cash only anyway.

I'm not cash only (for now) but this would still be my gut instinct for my practice. I suspect that if asked to visit with med students some patients would be openly hostile, and even more secretly resentful. People highly value the feeling of privacy in our work.

If I were wanting to give back with teaching I would look into having a side gig that allowed for it, e.g. occasional shifts at an academic psych ED, mentoring residents/students, teaching some didactics as a guest, etc.

 

[AD04]

I'm not cash only (for now) but this would still be my gut instinct for my practice. I suspect that if asked to visit with med students some patients would be openly hostile, and even more secretly resentful. People highly value the feeling of privacy in our work.

If I were wanting to give back with teaching I would look into having a side gig that allowed for it, e.g. occasional shifts at an academic psych ED, mentoring residents/students, teaching some didactics as a guest, etc.

I miss teaching medical students. But I will not have them in the practice as privileged patients don't want their secrets airs out to others.

 

[MedMan80]

I miss teaching medical students. But I will not have them in the practice as privileged patients don't want their secrets airs out to others.

This is absolutely my stance as well

 

[Crayola227]

I'd reach out to the clinical departments of the big schools, as Texas has requirements on who can rotate there. The big ones are AUC, ROSS, SABA, St. Georges U. To address the malpractice concerns, we were covered for clinical rotations and paid for malprac, if you are taking on an observer, these students are typically not covered by malpractice and certainly there's a greater risk of issues down the line if you let them do any meaningful clinical work. If you stick to MS4, you should be getting some highly motivated students that can help your productivity.

I agree with this, but at the last part, no one has mentioned what do you do when you get stuck with the really crappy MS4. Even if you get a motivated MS4 that wants to get into psychiatry, I imagine they can still manage to foul things up enough to cost you rather than saving you time.

I mean heck, I've never heard of a teaching attending NOT having a reduced case load when they have residents, at least without having greater hours (and I've been told usually even with reduced case load, hours are still often more, and compensation down) and they can actually write you billable notes and put in orders, and are actual doctors for crying out loud. I can see where good residents *might* save you some time, and last year seniors certainly should be capable of pulling some weight. I'm not sure where an MS4 falls in this, just that I can't imagine them being on that level.

The point being, you have no control over the quality of who you get, and you'll just have to make do with them. This happens to attendings with residents and students alike.

Also, especially with private practice vs inpatients, I can think of a thousand ways that a well meaning but bumbling student could trip over their words and deeply offend a patient, and it would have negative consequences for your practice and bottom line. I imagine if they're on medicaid and committed the outrage can only do so much. But in the case of a practice like this, I would think it could be pretty devastating.