Things I Hate About Third Year

[ProfMD]

I don't disagree with any of this, and I understand its not entirely medical schools' fault that things are how they are. It doesn't change the question, though: is there really a role for medical school clinicals in a world where its becoming legally impossible for medical students to really have clinicals? Is it ethical for schools to charge so much when they offer so little?

I would have to say that, yes, there is a role for med school clinical rotations. The quality needs to be improved - at least at the schools that the posters on this thread attend. For instance, med students should follow patients, write notes, present at rounds, formulate plans, call consults, follow-up on results, etc. The notes, whether they go in the chart or not, should be reviewed by a resident or attending.

Two of the reasons I think clinicals should not be abandoned are:
1) I do not want internship to be the first time a newly minted doctor experiences the clinical aspects of medicine. If it is, then the internship would undoubtedly become what M3 and M4 are now - observation.
2) I strongly feel that med students need the clinical experience to make an informed decision about their selection of speciality.

As far as the finances go, I would be curious if med school really would be cheaper if it were shorter. It seems that the most expensive years on a cost-per-student basis would be the first two. The second two should be relatively cheap other than providing malpractice insurance. Is it possible that the M3 and M4 tuition checks are really just subsidizing the M1 and M2 expenses?

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[sliceofbread136]

I would have to say that, yes, there is a role for med school clinical rotations. The quality needs to be improved - at least at the schools that the posters on this thread attend. For instance, med students should follow patients, write notes, present at rounds, formulate plans, call consults, follow-up on results, etc. The notes, whether they go in the chart or not, should be reviewed by a resident or attending.

Two of the reasons I think clinicals should not be abandoned are:
1) I do not want internship to be the first time a newly minted doctor experiences the clinical aspects of medicine. If it is, then the internship would undoubtedly become what M3 and M4 are now - observation.
2) I strongly feel that med students need the clinical experience to make an informed decision about their selection of speciality.

As far as the finances go, I would be curious if med school really would be cheaper if it were shorter. It seems that the most expensive years on a cost-per-student basis would be the first two. The second two should be relatively cheap other than providing malpractice insurance. Is it possible that the M3 and M4 tuition checks are really just subsidizing the M1 and M2 expenses?

I thought m1+2 were supposed to be cheap and m3+4 more expensive

 

[moisne]

Changing directions a bit... Im new to third year so I need to vent about this.

I have trouble taking this year seriously when I will be evaluated by attendings who barely interact with me. Its not their fault and I can tell some wish they had more time to teach. I will have had 4 attendings in 4 weeks. If you subtract the occasional clinic day that means each attending will have seen me for a grand total of 4 days. They only round with us so that means each has seen me for about 3h/day and 2 presentations/day for a total of 12 hours and 8 presentations (many of which are truncated or not actually done for the sake of speeding up rounds). They will never have read a note by me since I am supposed to just practice on my own time.

Yet I will be evaluated by these attendings. How can anybody take third year grades seriously? I'd like to think the modern era of attendings are acutely aware of the situation and put less stake in 3rd year grades when selective for residency, but it doesn't seem like that is the case from what I read.

In the past 2 weeks. I've had 9 attending and 9 residents. - I saw the attending maybe 5 minutes everyday. Can't wait for my eval!

 

[mcloaf]

I just read How We Die by Sherwin Nuland and he said that when he was a med student, he cut open someone's chest and started doing cardiac massage. That's unimaginable today.

The only part of this procedure a modern M3 would be reliably allowed to participate in is the transfer of the dirty dressings from the resident's hand to the trash can when they're taken down on the floor.

 

[ProfMD]

The only part of this procedure a modern M3 would be reliably allowed to participate in is the transfer of the dirty dressings from the resident's hand to the trash can when they're taken down on the floor.

I know you point this out to demonstrate how terrible M3 is now - but not doing open cardiac massage as a medical student is a good thing for the patient. When a person is actively trying to die, that is probably not the time for the med student to have hands in chest.

However, I do feel that med students should be involved in more routine cases. And by involved, I mean scrubbed and allowed to do some of the more basic tasks - retracting, suturing, etc. Maybe do more as they demonstrate ability and interest.

 

[mcloaf]

I know you point this out to demonstrate how terrible M3 is now - but not doing open cardiac massage as a medical student is a good thing for the patient. When a person is actively trying to die, that is probably not the time for the med student to have hands in chest.

However, I do feel that med students should be involved in more routine cases. And by involved, I mean scrubbed and allowed to do some of the more basic tasks - retracting, suturing, etc. Maybe do more as they demonstrate ability and interest.

I agree that certainly there is a range of what is and is not appropriate for an M3's level of training with the patient's best interest in mind. However as an M4 going into a surgical field I was giddy when I was allowed to bovie on omental fat for like 10 seconds the other day and I now love that attending, which probably gives a good idea of how much I'm able to do on an average case (my smoke suctioning and suture tail cutting levels are over 9000). It's terrifying to me that at some point in the not-so-distant future I'll be getting intern pages about lines and IV sticks when I've probably placed fewer than 5 IVs, no central lines, and 2 NG tubes, and not for lack of trying or enthusiasm. The scary part is that it's not just me complaining for my own sake, but patients are going to be the ones dealing with the consequences of me getting little training as a student. Yet somehow with an MD I become instantly qualified to do whatever at 3am when I haven't slept in 24 hours.

 

[ProfMD]

I agree that certainly there is a range of what is and is not appropriate for an M3's level of training with the patient's best interest in mind. However as an M4 going into a surgical field I was giddy when I was allowed to bovie on omental fat for like 10 seconds the other day and I now love that attending, which probably gives a good idea of how much I'm able to do on an average case (my smoke suctioning and suture tail cutting levels are over 9000). It's terrifying to me that at some point in the not-so-distant future I'll be getting intern pages about lines and IV sticks when I've probably placed fewer than 5 IVs, no central lines, and 2 NG tubes, and not for lack of trying or enthusiasm. The scary part is that it's not just me complaining for my own sake, but patients are going to be the ones dealing with the consequences of me getting little training as a student. Yet somehow with an MD I become instantly qualified to do whatever at 3am when I haven't slept in 24 hours.

I hear you - and I was there once too. I may have placed 1 or 2 CVLs and 1 or 2 a-lines as a med student. Fortunately, particularly in the early months, people will be there to back you up. At least they should be - if they are not then they are bad teachers.

He most important skill as an intern on call is to recognize who is sick and who isn't. Who can you work up, then call the senior and who needs more experienced people there now.

Internship is like drinking from a firehose, but it is amazing what you manage to take in.

 

[cbrons]

I wonder if M4 medicine subinternships will be just as worthless as the M3 clerkship. Does anyone with any experience have an anecdote about what you were and weren't allowed to do?

 

[Señor S]

I wonder if M4 medicine subinternships will be just as worthless as the M3 clerkship. Does anyone with any experience have an anecdote about what you were and weren't allowed to do?

1. Nice sig

2. At my school there are sometimes rules that allow 4th years to do more (e.g., 4th year students can intubate but 3rd years cannot). Of course, being allowed to do it and actually doing it are two different things, especially early in the year when the interns still don't feel comfortable yet...

 

[cbrons]

2. At my school there are sometimes rules that allow 4th years to do more (e.g., 4th year students can intubate but 3rd years cannot). Of course, being allowed to do it and actually doing it are two different things, especially early in the year when the interns still don't feel comfortable yet...

That's an interesting rule considering they allow CRNA students and paramedic students do that here.

 

[sloop]

That's an interesting rule considering they allow CRNA students and paramedic students do that here.

At my school, 3rd years can do just about anything that someone lets them do. It's weird to me that schools have rules about this. If you are supervised closely, I don't actually think there are many things that a med student shouldn't be allowed to do. My experience doing procedures on IM was not hampered by my being technically allowed to do it, but rather by the fact that the IM interns/residents at my program were for some reason still uncomfortable at procedures and trying to get experience themselves. For some reason every ABG got drawn by or was supervised by a senior resident and was performed under US guidance. It was bizarre.

Ironically, one of the rotations where I have been given the most autonomy to do procedures on patients and be most involved has been trauma surgery. Then again, the attending is just awesome and laid back (while still having everything under control) and wants students to be involved. During ex-laps and stuff he would also say things like "Is anything that we didn't do that someone still wants to do? Is there anything we missed, or is everyone comfortable with what we've done here? [med student name], that means you too. I'm serious, you're part of this thing too. Is there anything that you can think of that you'd still like to do?"

 

[Señor S]

That's an interesting rule considering they allow CRNA students and paramedic students do that here.

I should say that it isn't a school-wide rule but is rotation/service specific. And SRNAs get most of the pre-op intubations here too, so most people graduate without having done one.

 

[Psai]

I should say that it isn't a school-wide rule but is rotation/service specific. And SRNAs get most of the pre-op intubations here too, so most people graduate without having done one.

What the hell?

 

[Señor S]

What the hell?

?

 

[Psai]

?

You should be able to go from room to room and pick up a few

 

[Señor S]

You should be able to go from room to room and pick up a few

Huh? If there are a bunch of other trainees who need to do a certain number of cases, they're going to be doing it. Anesthesiologists here in general have a hands-off mentality too. Even the interns here don't intubate very much on their anesthesia rotations.

 

[cbrons]

I should say that it isn't a school-wide rule but is rotation/service specific. And SRNAs get most of the pre-op intubations here too, so most people graduate without having done one.

What the hell?

Could be wrong, but I would guess that the anesthesiologist groups and hospitals make good money from the CRNA diploma mills. Most MD schools do not pay attendings (or pay them very little) to teach.

On my anesthesiology rotation, my attending pushed me aside to the let the SRNA intubate my patients. She even let the SRNA lecture me on various topics, citing a recent story of how she was solo managing some incredibly complex pediatric case where the airway was lost in the middle of a spinal surgery on an 8 year old.

Was quite surprised that anesthesiologists are letting CRNAs much less SRNAs do those types of cases.

 

[Señor S]

Could be wrong, but I would guess that the anesthesiologist groups and hospitals make good money from the CRNA diploma mills.

Probably right. Always the dollars. Always the ****ing dollars.

 

[Psai]

Could be wrong, but I would guess that the anesthesiologist groups and hospitals make good money from the CRNA diploma mills. Most MD schools do not pay attendings (or pay them very little) to teach.

On my anesthesiology rotation, my attending pushed me aside to the let the SRNA intubate my patients. She even let the SRNA lecture me on various topics, citing a recent story of how she was solo managing some incredibly complex pediatric case where the airway was lost in the middle of a spinal surgery on an 8 year old.

Was quite surprised that anesthesiologists are letting CRNAs much less SRNAs do those types of cases.

:'(

Sins of the father

 

[alpinism]

I agree that certainly there is a range of what is and is not appropriate for an M3's level of training with the patient's best interest in mind. However as an M4 going into a surgical field I was giddy when I was allowed to bovie on omental fat for like 10 seconds the other day and I now love that attending, which probably gives a good idea of how much I'm able to do on an average case (my smoke suctioning and suture tail cutting levels are over 9000). It's terrifying to me that at some point in the not-so-distant future I'll be getting intern pages about lines and IV sticks when I've probably placed fewer than 5 IVs, no central lines, and 2 NG tubes, and not for lack of trying or enthusiasm. The scary part is that it's not just me complaining for my own sake, but patients are going to be the ones dealing with the consequences of me getting little training as a student. Yet somehow with an MD I become instantly qualified to do whatever at 3am when I haven't slept in 24 hours.

And now you understand why many interns are scared ****less during their first few months.

And why senior residents have to watch them like a hawk so that they don't kill anyone.

And why as a result neither of them has any time to teach medical students.

Its a vicious cycle.

 

[alpinism]

I wonder if M4 medicine subinternships will be just as worthless as the M3 clerkship. Does anyone with any experience have an anecdote about what you were and weren't allowed to do?

Just like M3 it depends on many different factors.

Usually you'll be given a little more responsibility and autonomy. But, then again, many rotations are still more or less glorified shadowing experiences. On the bright side, you're not at the bottom of the totem pole anymore and most students get a least a couple lines or tubes under their belt.

 

[Perrotfish]

Could be wrong, but I would guess that the anesthesiologist groups and hospitals make good money from the CRNA diploma mills. Most MD schools do not pay attendings (or pay them very little) to teach.

On my anesthesiology rotation, my attending pushed me aside to the let the SRNA intubate my patients. She even let the SRNA lecture me on various topics, citing a recent story of how she was solo managing some incredibly complex pediatric case where the airway was lost in the middle of a spinal surgery on an 8 year old.

Was quite surprised that anesthesiologists are letting CRNAs much less SRNAs do those types of cases.

This might be too cynical. If I was the attending I would definitely prioritize the SNRA over you regardless of the financial side of thing. That is the SNRA's last chance to learn under real supervision before (s)he goes out to manage airways with either distant supervision or none at all. Failing to teach the SNRA = killing future patients. The medical student, on the other hand, might not really need intubations at all (lots of us basically don't do them, or only in certain age ranges) and if a medical student needs to learn intubations there will be many years of Residency to do so.

There is an ethical argument for keeping students from doing procedures at all. We know that you are most likely to screw up a procedure the first few times you do it, and it exposes patients to needless risk to give students practice in procedures if you're not sure they'll go into a specialty where they'll use it as an attending. The only question is why we are forcing future Pediatricians to go through procedural rotations in procedures they'll never use again.

 

[Señor S]

There is an ethical argument for keeping students from doing procedures at all. We know that you are most likely to screw up a procedure the first few times you do it, and it exposes patients to needless risk to give students practice in procedures if you're not sure they'll go into a specialty where they'll use it as an attending. The only question is why we are forcing future Pediatricians to go through procedural rotations in procedures they'll never use again.

This is the issue exactly; you can't have it both ways. Also the "well, you're probably not going to end up doing this anyways" mentality unfortunately goes far beyond procedures now. I did 3 pelvic exams (not cervical checks, just regular pelvic exams) the whole 6 weeks of Ob/Gyn. There was literally nothing I got out of that rotation that couldn't be learned (better) from a book. A waste of time in the truest sense of the word "waste."

 

[TooMuchResearch]

Students what do you want from rotations? I have you in the ICUs and ED.

I edit and use student notes in the ICU. It's the only way they get feedback. Yes, it is more work for me than writing my own notes. In the ED, we also use student notes. Still more work than doing it on my own.

Procedures: I can get you some, but it's always a time issue. I can't supervise a student doing a line, would take too long. You are very unlikely to intubate in the ED or ICU at my place of employment, these are not good "practice patients." I'm probably not putting in IVs or NGs with you because the nurses do that, but you can see if the nurse will work with you on it for the experience.

what exactly do you want? I'd like to make your learning time as useful as possible.

 

[Señor S]

what exactly do you want?

To go home.

 

[NWwildcat2013]

Students what do you want from rotations? I have you in the ICUs and ED.

I edit and use student notes in the ICU. It's the only way they get feedback. Yes, it is more work for me than writing my own notes. In the ED, we also use student notes. Still more work than doing it on my own.

Procedures: I can get you some, but it's always a time issue. I can't supervise a student doing a line, would take too long. You are very unlikely to intubate in the ED or ICU at my place of employment, these are not good "practice patients." I'm probably not putting in IVs or NGs with you because the nurses do that, but you can see if the nurse will work with you on it for the experience.

what exactly do you want? I'd like to make your learning time as useful as possible.

I think it's great you use students notes. I'd value that feedback and I'm sure your students do as well.

Regarding procedures... That's a tough one and I don't know what to expect or what I'm should expect. Placing a line is a good example. In an ideal world I would learn that and you would have more time to teach me. That's what we all want but I understand the pressures placed on attendings and residents.


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[Psai]

Students what do you want from rotations? I have you in the ICUs and ED.

I edit and use student notes in the ICU. It's the only way they get feedback. Yes, it is more work for me than writing my own notes. In the ED, we also use student notes. Still more work than doing it on my own.

Procedures: I can get you some, but it's always a time issue. I can't supervise a student doing a line, would take too long. You are very unlikely to intubate in the ED or ICU at my place of employment, these are not good "practice patients." I'm probably not putting in IVs or NGs with you because the nurses do that, but you can see if the nurse will work with you on it for the experience.

what exactly do you want? I'd like to make your learning time as useful as possible.

Man every day I asked for lines and ivs on em, didn't get a single one. Was a headache just to get someone to teach me how to use the ekg. Had to teach myself how to use the ultrasound too.

 

[mimelim]

Man every day I asked for lines and ivs on em, didn't get a single one. Was a headache just to get someone to teach me how to use the ekg. Had to teach myself how to use the ultrasound too.

Come hang out with me... My MS3 got 3 lines this weekend on call with me. Brought her number up to 5 in the last couple of weeks. Yay for a weekend of, pages that say, "Central line consult: MICU" or "Central line consult: ER". It is really nice to get a consult in the OR and be able to send the MS3 to gather supplies, set everything up and then call me to do the actual line with them. Total time invested on my part ends up being 5 minutes of double checking the reasons for the line/patient and then 10-15 minutes to do the actual line... Our interns do >100 central lines/quintons in their first year, nobody ever gripes about giving them up.

 

[Psai]

Come hang out with me... My MS3 got 3 lines this weekend on call with me. Brought her number up to 5 in the last couple of weeks. Yay for a weekend of, pages that say, "Central line consult: MICU" or "Central line consult: ER". It is really nice to get a consult in the OR and be able to send the MS3 to gather supplies, set everything up and then call me to do the actual line with them. Total time invested on my part ends up being 5 minutes of double checking the reasons for the line/patient and then 10-15 minutes to do the actual line... Our interns do >100 central lines/quintons in their first year, nobody ever gripes about giving them up.

Man when I was rotating on vascular, I got all the supplies, set it up and the vascular second year did the femoral line with the gen surg fourth year supervising. A little part of me died that day

 

[HooliganSnail]

Yeah it's such a waste of time to know how the hospital works so that you have an idea what the problem is when something is held up instead of being all hurr durr where is da troponin or when your patient can't get an mri because they can't lay back and stay still for long enough.

And yes I have gone to the bathroom with a patient to get a urine sample. Even hand delivered it to the lab. EM docs can tell you that getting the urine sample holds things up all the time which you would know if you weren't sitting there playing on your phone all day wondering why no one will teach you.

Brilliant! First thing you do, before ANYTHING else.......get the f***ing urine sample.

It should be U, ABC. Urine, then lets see if you're breathing

 

[HooliganSnail]

Man when I was rotating on vascular, I got all the supplies, set it up and the vascular second year did the femoral line with the gen surg fourth year supervising. A little part of me died that day

I would be mortified to call the surgery team to do my central line.......just mortified.

 

[alpinism]

Students what do you want from rotations? I have you in the ICUs and ED.

I edit and use student notes in the ICU. It's the only way they get feedback. Yes, it is more work for me than writing my own notes. In the ED, we also use student notes. Still more work than doing it on my own.

Procedures: I can get you some, but it's always a time issue. I can't supervise a student doing a line, would take too long. You are very unlikely to intubate in the ED or ICU at my place of employment, these are not good "practice patients." I'm probably not putting in IVs or NGs with you because the nurses do that, but you can see if the nurse will work with you on it for the experience.

what exactly do you want? I'd like to make your learning time as useful as possible.

As a fellow EM resident, I've never liked these excuses.

1. Time - I can throw in a femoral line in 5 minutes. Even if it's students first time it takes me maybe another 5-10 minutes to teach and supervise. Its not like we're talking about spending an hour or even 30 minutes doing the procedure. Even in the busiest ED/ICU you can spare another 10 minutes. Honestly, I feel like most of the people who use this excuse just aren't comfortable teaching the procedure or have never done it before with students.

2. Practice patients - Outside of slam dunks in the OR, none of the patients in the ED/ICU are ever going to be "good practice patients." Why? Because usually if they need to be intubated they're really sick. Since most people aren't going into anesthesia, if they ever do need to intubate it will be on sick or crashing patients outside of the OR. These are exactly the patients they need to get see and get comfortable managing. With recent advances in airway management (i.e. video laryngoscopes and apneic oxygenation) its perfectly reasonable and safe to allow 1 quick attempt by students under supervision.

 

[alpinism]

Man every day I asked for lines and ivs on em, didn't get a single one. Was a headache just to get someone to teach me how to use the ekg. Had to teach myself how to use the ultrasound too.

Yeah that's BS. Either you were in a really slow ED or your residents just sucked.

 

[alpinism]

Variations in institutional practice patterns are interesting. At my hospital I've never heard of a general or vascular resident being called to place a line for another service

No kidding.

I've never seen a GS/VS resident called to the MICU/ED to put in lines.

 

[mimelim]

Variations in institutional practice patterns are interesting. At my hospital I've never heard of a general or vascular resident being called to place a line for another service

We have an official "We are not the central line service" policy. The only patients residents say, "Yes, we are on the way." for are our own patients or patients that someone else tried already and failed on. However, if someone persists after I tell them no twice, I am not going to let the patient suffer because of another provider's inability to provide care. For example, none of those lines over the weekend were technically challenging (hence the MS3 doing them), but there was something else at play that made me feel more comfortable with my MS3 and I doing it. I'm not a fool, I know that it opens me up to getting abused down the line, but when a provider says, "I haven't done a line in 15 years and don't feel comfortable doing it." I'm not walking away. Likewise, when a patient actually says (direct quote), "I will not let anyone but Vascular Surgery place a central line in me." I'm not walking away. Of course, I want to know #1 why a MICU patient knows that Vascular Surgery exists and why #2 they are so confident in us rather than the people taking care of them. But, at that point, the best thing for the patient is for me to patiently sort it out and have my MS3 place the line with me.

I deal with a lot of private doctors in all specialties, that may a part of why you guys don't see it as much.

 

[cbrons]

Students what do you want from rotations? I have you in the ICUs and ED.

I edit and use student notes in the ICU. It's the only way they get feedback. Yes, it is more work for me than writing my own notes. In the ED, we also use student notes. Still more work than doing it on my own.

Procedures: I can get you some, but it's always a time issue. I can't supervise a student doing a line, would take too long. You are very unlikely to intubate in the ED or ICU at my place of employment, these are not good "practice patients." I'm probably not putting in IVs or NGs with you because the nurses do that, but you can see if the nurse will work with you on it for the experience.

what exactly do you want? I'd like to make your learning time as useful as possible.

To see and present patients, not shadow. To write real notes. Procedures really arent important esp for M3s. Sounds like you are a good teacher.

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[deleted451730]

Students what do you want from rotations? I have you in the ICUs and ED.

I edit and use student notes in the ICU. It's the only way they get feedback. Yes, it is more work for me than writing my own notes. In the ED, we also use student notes. Still more work than doing it on my own.

Procedures: I can get you some, but it's always a time issue. I can't supervise a student doing a line, would take too long. You are very unlikely to intubate in the ED or ICU at my place of employment, these are not good "practice patients." I'm probably not putting in IVs or NGs with you because the nurses do that, but you can see if the nurse will work with you on it for the experience.

what exactly do you want? I'd like to make your learning time as useful as possible.

- Continue med students involvement in note writing, at least on a few pts daily. I was surprised by one preceptor who thought we didn't learn much from it; however, by doing so I felt I was allowed to be a part of the team at least in this small way. It intellectually/mentally made me much more engaged in the pt care and gave me the desire and guidance to actually at the end of the day go look up the management and medicine relevant to the case. Without the note writing, I usually tuned out during the shift mentally as I was dead weight then. Some of us are wired to require experiences to solidify knowledge rather than simply reading a book. Same thing with getting us involved in procedures no matter what specialty we are deciding on (remember, students' specialty choices often change in the course of third year). And...see and present pts as many times I was never asked to present well, only on EM and FM really.

- When there's literally nothing for us to do as the med students, even when we ask, SEND US HOME and don't assume someone else's job is to let us go, verbalize it! Back in the day in my opinion, learning on rotations was much more meaningful as students could do a lot more thus be more involved in pt care thus learn through experience by doing. Keeping a student just for them to serve their hours is pointless. In today's scene we often do diddly squat when things cool down (does standing overlooking someone's shoulder writing notes count as learning?), no thanks in part to malpractice and pts refusing students and that vicious cycle of upperclassmen's and other HCWs' learning taking priority over the med students' learning. Then we can also have more time to read up on the things physicians complain we know nothing about when pimped (instead of going home and crashing asleep instead of reading).

- Realize, too (unfortunately), that nowadays board scores are so much more vital and student evaluations are often so blandly generic that we (not me personally but many others) often tune out any knowledge that doesn't specifically pertain to teaching-to-the-test. Anything that isn't likely to be specifically on our board exams is one more piece of information that takes the space of another in our minds. I know students who appear to be lazy because they are sometimes nowhere to be found during lulls in shifts or cannot recall the mechanism of action of a drug no longer used, but actually many of them are studying or failing to find a spot in the hospital for students to sit and would rather study because of the aforementioned reality than stand around fetching blankets and walking labs down to pathology (I still enjoyed doing something). Perhaps being more aware of the unfortunate reality of how medical student education is now so heavily weighted?

Man every day I asked for lines and ivs on em, didn't get a single one. Was a headache just to get someone to teach me how to use the ekg. Had to teach myself how to use the ultrasound too.

Sometimes you have to be super obnoxious about getting others to show/teach you haha...

Man when I was rotating on vascular, I got all the supplies, set it up and the vascular second year did the femoral line with the gen surg fourth year supervising. A little part of me died that day

As a fellow EM resident, I've never liked these excuses.

1. Time - I can throw in a femoral line in 5 minutes. Even if it's students first time it takes me maybe another 5-10 minutes to teach and supervise. Its not like we're talking about spending an hour or even 30 minutes doing the procedure. Even in the busiest ED/ICU you can spare another 10 minutes. Honestly, I feel like most of the people who use this excuse just aren't comfortable teaching the procedure or have never done it before with students.

2. Practice patients - Outside of slam dunks in the OR, none of the patients in the ED/ICU are ever going to be "good practice patients." Why? Because usually if they need to be intubated they're really sick. Since most people aren't going into anesthesia, if they ever do need to intubate it will be on sick or crashing patients outside of the OR. These are exactly the patients they need to get see and get comfortable managing. With recent advances in airway management (i.e. video laryngoscopes and apneic oxygenation) its perfectly reasonable and safe to allow 1 quick attempt by students under supervision.

Yes 100%!

...and I've never seen GS consulted for a central line in the ED either.

 

[Psai]

Yeah that's BS. Either you were in a really slow ED or your residents just sucked.

Slow as hell, beds upstairs were always packed and turnover was low and partly the second part. Even had icu residents coming down to check on their patients cause no icu beds open

 

[jl lin]

Man every day I asked for lines and ivs on em, didn't get a single one. Was a headache just to get someone to teach me how to use the ekg. Had to teach myself how to use the ultrasound too.

Seriously, that is just wrong. How long does it take to teach someone to put the leads on and take an EKG? It is learning how to read EKGs which takes much longer and more practice. Placing an IV? Straightforward cases, sure? Why not? That's ridiculous.

 

[VA Hopeful Dr]

We have an official "We are not the central line service" policy. The only patients residents say, "Yes, we are on the way." for are our own patients or patients that someone else tried already and failed on. However, if someone persists after I tell them no twice, I am not going to let the patient suffer because of another provider's inability to provide care. For example, none of those lines over the weekend were technically challenging (hence the MS3 doing them), but there was something else at play that made me feel more comfortable with my MS3 and I doing it. I'm not a fool, I know that it opens me up to getting abused down the line, but when a provider says, "I haven't done a line in 15 years and don't feel comfortable doing it." I'm not walking away. Likewise, when a patient actually says (direct quote), "I will not let anyone but Vascular Surgery place a central line in me." I'm not walking away. Of course, I want to know #1 why a MICU patient knows that Vascular Surgery exists and why #2 they are so confident in us rather than the people taking care of them. But, at that point, the best thing for the patient is for me to patiently sort it out and have my MS3 place the line with me.

I deal with a lot of private doctors in all specialties, that may a part of why you guys don't see it as much.

Yeah in a teaching hospital I wouldn't expect surgery to get called on lines all that often. In a community hospital though...

 

[TooMuchResearch]

Variations in institutional practice patterns are interesting. At my hospital I've never heard of a general or vascular resident being called to place a line for another service

Yeah I've never heard of a central line consult.

 

[Raryn]

Variations in institutional practice patterns are interesting. At my hospital I've never heard of a general or vascular resident being called to place a line for another service

In three years of residency only once have I seen a medicine resident ask for a surgery consult for a line... and that's because the only residents in house at our VA that evening (from 5-8pm) was a relatively new Pgy2 and his interns (me included), none of which were signed off on lines. The surgeons were still in house and we asked for help rather than wait for the night residents or call our attending in from home (he'd have come in if we asked). The surgery chief was pretty magnanimous and supervised our PGY2 for the line.

Since I was signed off at the end of intern year, I've never called the surgeons to help with line placement and frankly would be baffled outside of that rare situation at any of our residents who would. If there's a super difficult patient where I fail at (or there's strong contraindications for) IJ, subclavian, and femoral... I'm probably running stuff through a peripheral or even placing an IO until I can get IR to do it under fluoro. Never gotten to that point personally though. (Did have one mega obese patient where I got it after failing several sites, but it happens)

On the topic of this thread though: I placed zero CVCs as a medical student, and of the 100 or so I've done as a resident, only done one with a medical student. If it's during the daytime, there's almost always an intern around that needs to get their numbers, and our medical students don't work nights.

That said, honestly, procedural competencies are the absolute least important thing for students to learn. The purpose of your M3/M4 years is to learn how to think and act like a doctor, the actual steps of where to stick a needle and how to hold the ultrasound probe are something that we could probably teach a primate. All the complaints above about not getting exposure to IV placement are missing the point.

 

[Señor S]

That said, honestly, procedural competencies are the absolute least important thing for students to learn. The purpose of your M3/M4 years is to learn how to think and act like a doctor

If not getting to do procedures was an isolated phenomenon then it wouldn't matter, but it's part of an overarching mentality where students are treated as disposable and education is perfunctory. I know everyone on SDN is the uber resident, a living embodiment of AAMC guidelines who goes out of his way to interact with and involve students, but in the real world M3s are mostly ignored and most of what they do is watch (and increasingly not even that).

 

[Wordead]

Well we (ENT) get consults to place dobhoffs, so not entirely surprising that vascular sometimes gets consulted for a line.

I think we've flipped out on the consulting teams enough that it's gone down dramatically, though.

 

[HelpPleaseMD]

Well we (ENT) get consults to place dobhoffs, so not entirely surprising that vascular sometimes gets consulted for a line.

I think we've flipped out on the consulting teams enough that it's gone down dramatically, though.

lol. wtf. asking subspeciality to plac dubhoffs and central lines -_- can't see any of that happened at where i train

 

[Psai]

Well we (ENT) get consults to place dobhoffs, so not entirely surprising that vascular sometimes gets consulted for a line.

I think we've flipped out on the consulting teams enough that it's gone down dramatically, though.

"Thank you for the opportunity to participate in the care of this fascinating and medically complex nasopharyngeal patient. Recommend nursing consult."

 

[mimelim]

In three years of residency only once have I seen a medicine resident ask for a surgery consult for a line... and that's because the only residents in house at our VA that evening (from 5-8pm) was a relatively new Pgy2 and his interns (me included), none of which were signed off on lines. The surgeons were still in house and we asked for help rather than wait for the night residents or call our attending in from home (he'd have come in if we asked). The surgery chief was pretty magnanimous and supervised our PGY2 for the line.

Since I was signed off at the end of intern year, I've never called the surgeons to help with line placement and frankly would be baffled outside of that rare situation at any of our residents who would. If there's a super difficult patient where I fail at (or there's strong contraindications for) IJ, subclavian, and femoral... I'm probably running stuff through a peripheral or even placing an IO until I can get IR to do it under fluoro. Never gotten to that point personally though. (Did have one mega obese patient where I got it after failing several sites, but it happens)

On the topic of this thread though: I placed zero CVCs as a medical student, and of the 100 or so I've done as a resident, only done one with a medical student. If it's during the daytime, there's almost always an intern around that needs to get their numbers, and our medical students don't work nights.

That said, honestly, procedural competencies are the absolute least important thing for students to learn. The purpose of your M3/M4 years is to learn how to think and act like a doctor, the actual steps of where to stick a needle and how to hold the ultrasound probe are something that we could probably teach a primate. All the complaints above about not getting exposure to IV placement are missing the point.

Practice patterns... We control virtually all the endo that we want at our hospital. Nobody would have IR place a line. We would place it under flouro. Or, if in a pinch/I was bored, I have dragged an x-ray tech to the bedside with a machine and done the line with a flat plate. I am in no way saying that that is a good thing in and of itself. But, it does mean that IR stays out of the complex endo that we DO want. Something that is somewhat unique to us also, 30%+ of our vascular patients are ESRD. This is obviously way above normal for a typical tertiary care center and a reflection of how some of the practices were built. This means that our central occlusion/stenosis rate is way outside the bounds of what people will see normally. Also with the high number of ESRD patients, the number of patients that need a quinton per day is actually quite high. We have 40+ nephrologists that come to our hospital and none do quintons, so it falls to us.

Regarding students and learning about central lines. I agree that students should not get hung up on doing or not getting to do procedures. But, in the same way that learning how to take a good H&P is incredibly important, learning about IV and central IV access is important for anyone that is going to be in the inpatient setting. The number of inappropriate line placements is staggering, as is the complication rate (talking globally, not just at our hospital). At least once a month we get a referral from the community for a patient with a retained guidewire. Being exposed to and forced to think about WHY a line is being placed is good for medical students. Regardless of the specialty they are going into...

 

[VA Hopeful Dr]

Practice patterns... We control virtually all the endo that we want at our hospital. Nobody would have IR place a line. We would place it under flouro. Or, if in a pinch/I was bored, I have dragged an x-ray tech to the bedside with a machine and done the line with a flat plate. I am in no way saying that that is a good thing in and of itself. But, it does mean that IR stays out of the complex endo that we DO want. Something that is somewhat unique to us also, 30%+ of our vascular patients are ESRD. This is obviously way above normal for a typical tertiary care center and a reflection of how some of the practices were built. This means that our central occlusion/stenosis rate is way outside the bounds of what people will see normally. Also with the high number of ESRD patients, the number of patients that need a quinton per day is actually quite high. We have 40+ nephrologists that come to our hospital and none do quintons, so it falls to us.

Regarding students and learning about central lines. I agree that students should not get hung up on doing or not getting to do procedures. But, in the same way that learning how to take a good H&P is incredibly important, learning about IV and central IV access is important for anyone that is going to be in the inpatient setting. The number of inappropriate line placements is staggering, as is the complication rate (talking globally, not just at our hospital). At least once a month we get a referral from the community for a patient with a retained guidewire. Being exposed to and forced to think about WHY a line is being placed is good for medical students. Regardless of the specialty they are going into...

That and for a med student, being able to do a line was the highlight of my week.

 

[badasshairday]

Well we (ENT) get consults to place dobhoffs, so not entirely surprising that vascular sometimes gets consulted for a line.

Really? At most places you can just send the patient down to radiology and we can advance it under fluoro. Done deal.

As for consulting surgeons for a central line? That is rare too. Radiology can usually get it done faster as well.

A lions share of procedures which are classically done by specialists are done by radiologists (non-interventional) these days. Image guided biopses, LP's, dobhoffs, G-tubes, central lines. And why not? Radiologists can get it done quickly, efficiently, and safely with image guidance. Best of all, our standard answer to your consult is "yes".

 

[Wordead]

Really? At most places you can just send the patient down to radiology and we can advance it under fluoro. Done deal.

As for consulting surgeons for a central line? That is rare too. Radiology can usually get it done faster as well.

A lions share of procedures which are classically done by specialists are done by radiologists (non-interventional) these days. Image guided biopses, LP's, dobhoffs, G-tubes, central lines. And why not? Radiologists can get it done quickly, efficiently, and safely with image guidance. Best of all, our standard answer to your consult is "yes".

I think it happened more towards the beginning of the year when people were getting their legs under them; they tapered off a bit further into the year. It's still shameful for any surgical service to call ENT for it though. And a huge waste of our time. I'm more than happy to let radiology take care of those "consults", but that doesn't really happen here. I think fluoro is absolute overkill anyhow for a NG/dobhoff. Unless a patient has real stenosis or altered anatomy it's usually because the team is just shoving it in and hoping for the best instead of positioning the patient properly.

I can't say I've seen radiology do G-tubes. Curious how that works.