teaching students

[penguins]

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Question:

I didn't work much with residents/interns as a medical student so I am really at a loss as to what to do with the medical students. What do they do and what is expected of them? I realize this is a general question and varies from institution to institution. However, I have been surprised to hear things from other interns about how much work they are expecting to give their medical students. It almost seems as though in some electives, the med students have "priority" over the interns as far as teaching/responsibility.

BTW, starting internship in a couple days. 😳

 

[alreadylernd]

As a med student who just finished 3rd year, I think the advice I would give (and plan on following myself in just a little over a year) is:

1. Always set clear expectations about responsibilities - medical students don't know what to expect, and expectations always vary from rotation to rotation, resident to resident. At least if you're clear about YOUR expectations, they have a chance.
2. Especially early on, let the med student know what he/she should be doing.
3. Let the med student know when he/she can leave. I know I was always afraid to leave early, even if there was nothing for me to do!
4. Let the med student know if he/she is doing something WRONG. No one likes to be told "oh yeah, you're doing fine" and then the evals come out and it says things like "didn't do xyz" (Not that this ever happened to me, I just heard it sometimes happens 😉 )
5. A lot of times we're just looking to learn. Remember, often we have NO clinical experience and know NOTHING about hospital protocols. Sometimes even the most mundane things are new.

6. Always give the med student all your meal tickets. This one is a must! (just kidding)

Question:

I didn't work much with residents/interns as a medical student so I am really at a loss as to what to do with the medical students. What do they do and what is expected of them? I realize this is a general question and varies from institution to institution. However, I have been surprised to hear things from other interns about how much work they are expecting to give their medical students. It almost seems as though in some electives, the med students have "priority" over the interns as far as teaching/responsibility.

BTW, starting internship in a couple days. 😳

 

[zedpol]

As a med student who just finished 3rd year, I think the advice I would give (and plan on following myself in just a little over a year) is:

1. Always set clear expectations about responsibilities - medical students don't know what to expect, and expectations always vary from rotation to rotation, resident to resident. At least if you're clear about YOUR expectations, they have a chance.
2. Especially early on, let the med student know what he/she should be doing.
3. Let the med student know when he/she can leave. I know I was always afraid to leave early, even if there was nothing for me to do!
4. Let the med student know if he/she is doing something WRONG. No one likes to be told "oh yeah, you're doing fine" and then the evals come out and it says things like "didn't do xyz" (Not that this ever happened to me, I just heard it sometimes happens 😉 )
5. A lot of times we're just looking to learn. Remember, often we have NO clinical experience and know NOTHING about hospital protocols. Sometimes even the most mundane things are new.

6. Always give the med student all your meal tickets. This one is a must! (just kidding)

well said, just to add a couple

1)don't be afraid to give your medical students responsibility after you have shown them what you want.

2)do your best to make your medical students look good in front of the attendings, we will return the favor. (assuming your medical student isn't a complete idiot)

3) for the most part we aren't stupid, we just lack experience.

z

 

[AmoryBlaine]

I would definitely say to always provide constructive criticism if it is warranted. It's not easy to hear an attending say, "that was a good presentation but here's what you could do better," but that's when you end up learning. Especially when that doc says, "great job, that was a alot better" on the next one.

The thing that kills me is when docs just say "that was fine" when I ask for tips, surely there's something I can improve upon. This is especially frustrating after a bumbling presentation dealing with multiple complaints when I know I didn't do a good job.

Thanks for asking.

 

[PMR TX MS]

Give constructive criticism of course. But, don't forget the need for positive feedback. The first time you go through something, there's a lot of uncertainty in the mind of a student. Third year is not easy and most lack confidence. A nice encouraging word (hopefully genuine 🙂 goes a long way towards becoming a good physician.

 

[lvspro]

Hi
Think back to 3rd & 4th yrs when you had good and bad interns. Everyone has diferent experiences, but for me I have a few interns I'll be emulating... for example:
1. I had one intern teach me how to write a note, and a damn good one. Little things I didn't think of at the time like writing trends in Hg, or WBC etc..., ended up being pretty important.
2. Said intern also would re-examine a pt, and point things out I had no idea existed... waterhammer pulses, or maybe a jacksonian march. I remember mentioning those things on different pt's during presentations and the attending commenting on my exam skills, and knowledge base. I was happy, and did well on those rotations.
3. Intern would give me a clear explanation on how to do things, ie d/c, admit, write orders, write Rx's. Then after one or two supervised runs, would send me to do said jobs.
How did I reward said interns?
1. New pt... I'd write them up, get any old stuff/labs/imaging, and have it ready for them.
2. Pt waiting for X-ray... I'd physically wheel the pt down to get studies done.
3. Waiting for radio report? Again, I'd run down to get them ready.
4. Time to d/c /admit/write Rx's? I'd have it all done so all they'd have to do is sign it.

I guess the long and short of it is that if you teach a med student how to do things, they'll make your life easier by covering a ton of scut.

BTW, if you send a student to pick up food, at least offer to toss in a cuppla bux towards their food. It's so much more genuine than saying "I don't wanna scut you out, but do you wanna go get us some ndn food."

Start internship tomorrow w/students, and I hope I can live up to my expectations of myself. 😳

 

[Tater]

Ha!! 😛 And realize this: Right now its the blind leading the blind, my friend. I think luckily for us, the med students don't come on service until the 10th of July. At least we have a little time to look like bumbling idiots so you don't completely doubt our intelligence. 😀

 

[Sugar72]

We have medical students coming on tomorrow and I hope it is an ms4 so they can teach me how to use the freaking computer system! Oh yeah and tell me where radiology is.

 

[emtcsmith]

I'm a paramedic student but still feel I could throw a few good things in here:
-After working on a patient, preforming some procedure, etc I think the student can learn double from the event if afterwards the preceptor sits down with them and reviews what happened, good, bad, things to change, etc

-Set goals, guidlines, expectations...student needs to know whats going on, what you want done, and what to and not to do.

-Be open and honest. If the student is doing something wrong, tell them that and then take the time to show them the correct way. The worst thing you can do is say "you did it all wrong" and then fix it yourself. Someone is never going to learn unless they are shown the correct way to do something.

-If you are not sure about something don't tell the student incorrect information.

-Allow your student to take the lead, push them out in front if they are shy but they have to learn and learning invloves many levels of hands on, etc.

 

[penguins]

Hey,
I appreciate everyone's imput. Good reminders.

What I am really wondering though, is what do we have students do? Like I said, I didn't work much with residents as a med student - just directly with attendings. So I don't know what they are supposed to do or how the tasks are split up.
Do I send them to see new patients, to do the H&P, or only after I have already seen them and done the admit orders, etc. I don't want to have them just be gofers, so what do I ask them to do when they ask?
Does the med student "report" to the intern or to the 2nd year resident or usually to the attending?

I enjoy teaching although right now I am sure that they could teach me more than I can teach them at this point. I think back and think I knew alot more as a 3rd, or fresh 4th year than I do now!!!

Thanks!

 

[Chrismander]

Ideally the first day on call with the med student (assuming you two are always on call together and he isn't being swapped between interns) when you have the time and if the service isn't at 150% capacity, go down to the ER together, make him do the H&P without seeing you do it first, and then do your own right then and there with him present so he sees what he missed.

Take time afterward to talk about his H&P, give feedback on how to make it more structured/systematic/thorough/whatever, and then have him write it up (he probably has to write it up anyway for his clerkship, or at least he'll need something handy to read off of for presenting to the attending at rounds the next day). His presentation skills will be terrible if this is his first rotation (everyone's are, and no one sticks to the right format), so make him do that presentation for you at least twice the first night, if you have time. From here on out, whenever possible, have him go see the patients first for admission H&P's, unless absolutely necessary. After a few, you don't need to be physically in the room anymore, and he doesn't need to watch you (unless he's doing poorly and needs the extra remediation). But always compare notes afterwards, to make sure that he asked all the pertinent questions and found all the pertinent findings that you did--he won't have, and that's the point.

Check his H&P writeup to make sure that it's written appropriately--your goal, if your hospital allows it, is to have him do the *entire* H&P and progress notes for all of his patients with you just annotating here and there and then countersigning. Obviously, this won't happen until several weeks into the clerkship, when he finally learns how to write an H&P or progress note that's marginally usable. By the end, you want him functioning as a sub-sub-intern, taking full responsibility for his clutch of 2-3 patients or whatever, and not just following you around like he's job shadowing. (check with him/his syllabus/the clerkship director/other interns/the resident to find out how many he's supposed to carry or admit per call night).

Obviously repeat the same thing with the daily progress notes. Be a stickler on progress note quality--just keep asking yourself if what he wrote as a note would be acceptable if you just countersigned it without further modification. If it's just a knowledge thing, this is a quick 1 minute teaching opportunity. If it's a note structure / incompleteness / messiness / incoherence thing, be harsh on the note, but not on the student. He'll thank you for it later, unless he's a complete idiot. My first intern on medicine told me not to write notes, since it was faster for him to do it himself. I thought he was the coolest dude at the time because of that, and because he sent me home at like 3 every day. In retrospect, he was my worst intern, because i didn't learn how to function independently until later in the clerkship.

Good luck with your little penguins...

Hey,
I appreciate everyone's imput. Good reminders.

What I am really wondering though, is what do we have students do? Like I said, I didn't work much with residents as a med student - just directly with attendings. So I don't know what they are supposed to do or how the tasks are split up.
Do I send them to see new patients, to do the H&P, or only after I have already seen them and done the admit orders, etc. I don't want to have them just be gofers, so what do I ask them to do when they ask?
Does the med student "report" to the intern or to the 2nd year resident or usually to the attending?

I enjoy teaching although right now I am sure that they could teach me more than I can teach them at this point. I think back and think I knew alot more as a 3rd, or fresh 4th year than I do now!!!

Thanks!

 

[angel80]

When I was a third year, the intern would send me to go do an H&P on a new patient. When I was done, I would page the intern, and go over the case with him/her. We would then go see the patient again together. The intern would ask the patient things that I missed, and redo the exam. We would write the admit orders together. I would write notes on my patients in the morning, then, depending on the intern, they would either write a shorter note after mine, or just co-sign mine.

 

[Chrismander]

One more thing penguins--you asked who the students report to. I'm sure there's some variation out there (sounds like your school didn't even have residents/interns on the same teams as med students) but the general model seems to be this:
All the patients on the service are "owned" by the interns. A student follows a certain patient or two at the beginning, and later when he (and the intern) are comfortable with him having more responsibility, he "pretends" he's the intern and writes all the daily notes, etc. But unlike the sub-I, the student can't write orders, sign notes, etc etc. So the student has to report to you at least each morning to inform you on the patient's status (you'll be seeing the patient yourself anyway) and to get that note signed or at least get you two on the same page before morning report/rounds, and then also to have you put in any orders that need to get done.

You and the student should be in constant communication cause the patient is essentially shared--if the student starts acting like he "owns" the patient and reports directly to the resident and attending, you'll get cut out of the loop and not know crucial things. This can happen either cause the student's an idiot or a douchebag (or cause you ticked him off) so your best bet is to check up on the patient like the student didn't exist (since you're still their real doctor and the buck stops with you) but give the student free reign to present all information about the patient to the resident during work rounds, to the attending on teaching rounds, to make all phone calls to consultants, etc. Or alternatively (though i haven't seen this happen cause an intern'd have to be damn stupid...but still) since the patient is "shared" both might shirk their responsibilities or not take full ownership--the intern might think the student knows everything about the patient....then when the student fails to answer the attendings question about a patient's lab value, imaging result, exam finding, etc, and turns to the intern for the answer... well, you get the drift. 🙂

 

[fab4fan]

lvspro wrote:

Intern would give me a clear explanation on how to do things, ie d/c, admit, write orders, write Rx's. Then after one or two supervised runs, would send me to do said jobs.

This is so important. In the last week, I've had an MSIV med student who didn't know how to write an Rx (doc signs it) and an intern who did not know how to do an H&P without coaching.

As a nurse, I understand that it's the "new year" for you guysand there are bound to be glitches, but programs shouldn't be throwing students and interns out in the cold, either.

 

[penguins]

Ideally the first day on call with the med student (assuming you two are always on call together and he isn't being swapped between interns) when you have the time and if the service isn't at 150% capacity, go down to the ER together, make him do the H&P without seeing you do it first, and then do your own right then and there with him present so he sees what he missed.

Take time afterward to talk about his H&P, give feedback on how to make it more structured/systematic/thorough/whatever, and then have him write it up (he probably has to write it up anyway for his clerkship, or at least he'll need something handy to read off of for presenting to the attending at rounds the next day). His presentation skills will be terrible if this is his first rotation (everyone's are, and no one sticks to the right format), so make him do that presentation for you at least twice the first night, if you have time. From here on out, whenever possible, have him go see the patients first for admission H&P's, unless absolutely necessary. After a few, you don't need to be physically in the room anymore, and he doesn't need to watch you (unless he's doing poorly and needs the extra remediation). But always compare notes afterwards, to make sure that he asked all the pertinent questions and found all the pertinent findings that you did--he won't have, and that's the point.

Check his H&P writeup to make sure that it's written appropriately--your goal, if your hospital allows it, is to have him do the *entire* H&P and progress notes for all of his patients with you just annotating here and there and then countersigning. Obviously, this won't happen until several weeks into the clerkship, when he finally learns how to write an H&P or progress note that's marginally usable. By the end, you want him functioning as a sub-sub-intern, taking full responsibility for his clutch of 2-3 patients or whatever, and not just following you around like he's job shadowing. (check with him/his syllabus/the clerkship director/other interns/the resident to find out how many he's supposed to carry or admit per call night).

Obviously repeat the same thing with the daily progress notes. Be a stickler on progress note quality--just keep asking yourself if what he wrote as a note would be acceptable if you just countersigned it without further modification. If it's just a knowledge thing, this is a quick 1 minute teaching opportunity. If it's a note structure / incompleteness / messiness / incoherence thing, be harsh on the note, but not on the student. He'll thank you for it later, unless he's a complete idiot. My first intern on medicine told me not to write notes, since it was faster for him to do it himself. I thought he was the coolest dude at the time because of that, and because he sent me home at like 3 every day. In retrospect, he was my worst intern, because i didn't learn how to function independently until later in the clerkship.

Good luck with your little penguins...

Thank you so much! That is exactly the kind of advice I was looking for. I really appreciate it!!

 

[fireflyrxn]

it's really important to distinguish between having students "who are allowed to write notes" and "co-signing". at our hospital, we were flat out told that we were not allowed to co-sign student notes because the documentation would not count for billing purposes. only resident and attending notes (i.e., MD notes) count. co-signing sub-I or clerk notes doesn't mean a hill of beans in some places.

 

[Tater]

it's really important to distinguish between having students "who are allowed to write notes" and "co-signing". at our hospital, we were flat out told that we were not allowed to co-sign student notes because the documentation would not count for billing purposes. only resident and attending notes (i.e., MD notes) count. co-signing sub-I or clerk notes doesn't mean a hill of beans in some places.

Sorry I didn't answer your PM, dude. When we were walking through the ICU, I wanted to say, "I'm on SurgOnc, goofball!" but you guys looked busy. 😛

I wish we had students right now. Call would be a little less lonely. I've decided that I'll ask my students to see a couple interesting patients so we can discuss assessment/plan, get vital signs, and I'll teach them how three chamber chest tube systems really work. And then they'll go to the OR, lectures, etc. In all actuality, I don't think the med students will really be spending all that much time with us. But if you're on transplant...all bets are off. You're going to get scutted to death.

 

[gutonc]

My univ. hospital requires a resident/attending addendum to notes for them to be legit. A simple, "I have seen and examined pt. and agree w/ the MS A/P as outlined above" is good enough. Most people add a little extra, particularly where the student note is vague or wrong but, in general they're usually brief. At the VA, notes need an attending co-signature and orders need a resident or attending co-signature. Since it's all electronic and can be done in batches though, it becomes kind of meaningless.

BE (now PE)

 

[JackBauERfan]

it's really important to distinguish between having students "who are allowed to write notes" and "co-signing". at our hospital, we were flat out told that we were not allowed to co-sign student notes because the documentation would not count for billing purposes. only resident and attending notes (i.e., MD notes) count. co-signing sub-I or clerk notes doesn't mean a hill of beans in some places.

yeah same about my institution. Other places I have been you can co-sign, just depends I guess.

 

[anamarylee]

From an MSIV:
Explain on the first day what you expect of them. There is nothing worse than the feeling you get as an MS just standing there not know what to do.
If you are going to do a procedure, invite the student to watch. Explain what you are doing step by step. It's really intimidating at first for students to do things that are second nature to residents (ABGs, starting lines, etc).
If the students have to do case presentations, and an easy case comes along, let them know. We really appreciate this.
If you have the time, show them where the lab, radiology, medical records is. I didn't mind fetching reports for my interns as long as I knew where everything was.
Teach them how to use the computer system (if there is one in your hospital) so they can use it.
Don't keep them in the hospital longer than they have to be. Your day ends when you leave the hospital, but students have to study for exams, case preparations, etc.

 

[Surgeon24]

I agree with all of what have been said.

In summary, don't be a jackass, respect the med student (he will be your colleague in a few years), and teach him some stuff if you have time.

As a nurse, I understand that it's the "new year" for you guysand there are bound to be glitches, but programs shouldn't be throwing students and interns out in the cold, either.

Ah, pure truth!!! Did you ever compare how a med student learns about asepsy compared to a new nurse in the operating room??? The nurse teacher has her nurse-student by her side, and shows her everything she's doing, tells her why and how she's giving the instruments to the surgeons, what and where to touch/or not to touch, etc...

How about the med student?

He or she is just thrown in the operating room and screamed at 'DON'T TOUCH THE BLUE STUFF'...then we screw up and everyone thinks we're dumb.

This is pure beauty...medicine is the ultimate test of adaptation. I don't think there's another profession where you're thrown in the middle of new land each couple of months and you're expected to perform as if you knew wtf you are doing.

 

[raptor5]

Never assume that b/c a student has no interest in pursuing your specialty that he/she has no interest in learning the details. I had this happen on an ortho rotation. I thought the attendings just didn't teach until a fellow student expressed interest in ortho and was treated like a resident.

 

[sophiejane]

Did you ever compare how a med student learns about asepsy compared to a new nurse in the operating room??? The nurse teacher has her nurse-student by her side, and shows her everything she's doing, tells her why and how she's giving the instruments to the surgeons, what and where to touch/or not to touch, etc...

How about the med student?

He or she is just thrown in the operating room and screamed at 'DON'T TOUCH THE BLUE STUFF'...then we screw up and everyone thinks we're dumb.

This is pure beauty...medicine is the ultimate test of adaptation. I don't think there's another profession where you're thrown in the middle of new land each couple of months and you're expected to perform as if you knew wtf you are doing.

This is so true.

I have to say, one of the best teachers I had in my 3rd year was an NP. She taught me to suture--she was patient, encouraging, and told me what to do every step of the way and then watched while I took a few stiches on my own. (Fortunately, the patient was really patient and was even cheering me on!)

Why don't we get taught like that all the time? Is it just because docs are too busy to take the time...or are we just propogating the insults we received in our training onto the next generation?

 

[Mumpu]

From an intern to the MS3/4's:
Take charge of your education. If you want to learn and be taught, make yourself present. If you are running personal errands all day or napping in the call room, I will not necessarily take the time to page you to point out some tidbit of incidental teaching because I am busy. If you are in the vicinity, I will happily take the minute it would've taken me to page you to teach you something. I have two MS3's now -- one always around (not annoyingly on my neck, just always physically present), and one always elsewhere. One has gotten considerably more teaching from me and other interns and residents than the other. Along the same lines, if I say "let's meet 15 minutes before rounds to go over your presentation" and you don't show up, I won't page you -- I'm not your mom, I will happily finish my notes instead. Presumably, if you made it to graduate school you are mature enough to act as a responsible adult.

Yes, I do sound irate. 😛 The reality is that I love teaching but I also have a ton of work to do. Make it easy for me to teach you (show up) and you will be the star.

For interns/residents, I think "praise in public, criticize in private" is generally the best approach.

 

[Doc Ivy]

From an intern to the MS3/4's:
Take charge of your education. If you want to learn and be taught, make yourself present. If you are running personal errands all day or napping in the call room, I will not necessarily take the time to page you to point out some tidbit of incidental teaching because I am busy. If you are in the vicinity, I will happily take the minute it would've taken me to page you to teach you something.

Mumpu, while I don't doubt that you mean this, I have found that this isn't always the case. A lot of residents don't teach even if you are around, as a med student after a while one starts to get sick of just "hanging around being useless" and wonders if they might be making better use reading in the library. Teach me something, scut me out, just don't have me stand here watching you work.

I also have to agree that just because I don't want to do OB doesn't mean you shouldn't teach me to do a pelvic exam on a laboring woman!!! I have seen variations on this theme all of 3rd year. Some of us really do want to learn about xyz while not having a desire to make it our career. Don't check out on us because we don't want to do your field.


And to reiterate someone's point: what is scut to the resident is valuable teaching to the student sometimes. What's old hat to you is very new to us.

 

[souljah1]

In addition to all the practical stuff of day to day activities i.e. notes, orders, d/c, etc - one of the best things you can do for medical students that you may work with is to:

1. Think out loud during time periods where medical decisions are made. Instead of entering the room of a patient with new onset A fib and telling the nurse to get an ECG, fluids, and some IV metoprolol - think out loud about the different causes of A fib, why giving fluids may be appropriate or not, ask what drug he/she would choose and then explain your rational for IV vs PO/ dilt vs metop, etc. When you just enter a room and start going through the motions without thinking out loud, most students wind up feeling peripherally involved at best. When you talk out loud and include them in the basic decision making it keeps them involved, actively thinking, and makes it more likely for them to learn something from the 'clinical moment'. Then afterward, you can sit down and go over the pathophysiology, differential, work-up, whether or not cardioversion is appropriate, treatment, etc if time permits. It makes it all sink in much faster.

2. Cut out some time (usually on call nights) to go view all the films on our patients and have your medical student interpret them. when my resident did this with me I was a bumbling fool at first, but after a while I learned a systematic approach that really sunk in. ECG's are another data set that you can really hammer home key points in.

3. Eye ball their patient first and get a sense of the most important problem or two that will need to be addressed. Then, (if time) pull some evidence-based articles. Have them write up their history and physical and tell them to think about their assessment and plan. Then, take some time and go over the one or two most important problems focusing on the differential and work-up. Chalk talks work great for this. Then, after they have a much better sense of how to approach formulating their assessment and plan - give them the article(s) to read to help them solidify concepts.

I think learning in the ways I mentioned above is much better than giving a quick talk about subjects that may be unrelated to their patients.

There is no such thing as a non-teachable moment.

 

[Mumpu]

Very good points Souljah! One and Two are very easy to do, Three takes a bit more skill and efficiency which is still borderline for most interns this time of the year.

Ivy, read in the residents' work room where we all hang out most of the day, not in the library. Even if I don't have time to teach you something at the moment, if I physically see you I will almost always say "let's meet at this time and I'll teach you about something." Much less likely to happen if I'm busy and I have to page you.