What it means to "work hard"

[koan]

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Looking forward to starting rotations this summer. Everything I read and the advice from those ahead says that if you keep a positive outlook, be as helpful as possible, and "work hard" you (may or may not) be evaluated well by attendings. I'm looking for some clarification / examples of what working hard entails. Or an example of what not to do would be equally helpful. Hard work is easy to define in manual labor, but with rotations and the complex / unpredictable / useless role of a third year student, I need more tangibles. Are we talking about scut?

 

[45408]

1. Avoid prolonged breaks to smoke/eat/call your girlfriend/go to the bathroom at an inopportune moment.
2. See patients efficiently, document your findings as soon as possible, be thorough but not ridiculous.
3. Be on time, every time. On time means at least a few minutes early. There is rarely an excuse to be late.
4. Don't announce that you have lecture at 1pm, so you need to leave at 11:30. We all know how long it takes to get there.
5. Team has a new consult/admit? Offer to go see it.
6. Team is sitting around, looking bored? Ask to talk through a common scenario (chest pain, abd pain) or see if an attending has clinic you could do.
7. I will nearly always think it's reasonable for you to get lunch, but if there's really some sh-t flying, your education will suffer sometimes if you bail out for food, so keep a snack bar in your pocket if you can't focus on an empty stomach.
8. If you start following a patient, stick with them. If you're in doubt as to whom you should be following, ask the team. I'm never going to assign a student to a patient who's been camped out for 3 weeks on TPN.
9. If there's a conference/operation the next day, read about it. Be prepared. Know the disease/topic/patient and be able to speak intelligently about it. A 3x5 card can be very useful to remind you "Okay, 67 y/o M with hepatic flexure colon CA, plan is to do an extended R hemicolectomy, co-morbidities include diabetes, HTN. Prior abd operation is a gastric bypass."
10. Look interested. Be interested. You do not have to lie to me and say you want to do surgery, because I will try to tailor your experience to something useful, but don't sit there looking bored all day, please.
11. Know what is happening to your patients and when. If your pt is getting a CT scan to see if they need an operation/procedure, then you should not be the last person to know. You could go with the pt to the scanner or go review the images with the radiologist, so that you're the first one to know what it shows.


A few lousy residents might scut you out a lot, but if it involves seeing patients, medical decision-making, expediting patient care in an urgent situation (I'll draw blood, take a pt to the CT scanner and watch the scan, wheel them into the OR, place a Foley, review images with the radiologist, etc), or coordinating care for your patient, then it isn't scut.

 

[koan]

great advice, thanks

 

[swamprat]

Even so, its all a crapshoot as far as grades go since its mostly subjective and some docs don't understand the "meets expectations" category doesn't help anyone's cause. But yeah basically wat above poster said is all true except usually a lot more scut than what that poster leads you to believe in my experience. I personally don't mind it because I'd rather do that than stand around while you put in orders or something thats really the worst.

 

[45408]

Even so, its all a crapshoot as far as grades go since its mostly subjective and some docs don't understand the "meets expectations" category doesn't help anyone's cause. But yeah basically wat above poster said is all true except usually a lot more scut than what that poster leads you to believe in my experience. I personally don't mind it because I'd rather do that than stand around while you put in orders or something thats really the worst.

Maybe it's school dependent, because I neither did much scut nor handed it out. Again, if it involves seeing patients, medical decision-making, expediting patient care in an urgent situation, or coordinating care for your patient, then it isn't scut. Getting coffee, making copies for someone's research project, etc. is scut.

 

[Bacchus]

Prowler, is that a mix of 3rd/4th year advice or one year moreso than the other?

 

[swamprat]

Maybe it's school dependent, because I neither did much scut nor handed it out. Again, if it involves seeing patients, medical decision-making, expediting patient care in an urgent situation, or coordinating care for your patient, then it isn't scut. Getting coffee, making copies for someone's research project, etc. is scut.

Yeah u know some of the residents will actually apologize and say "sorry to scut you out, but..." And some of the stuff is involved with patient care for example faxing for medical records (and of course dealing with the unhappy case managers who are pissed your using their fax machine), running down non-stat labs, running down to get final reads from radiology to turn pts over faster. I know some of it is necessary but using med students as the gofer every time prob counts as scut. Then theres the patient transport which I know as a resident most feel is scut but we hafta do it most of the time, again idk if I'd consider that scut but don't they have transporters to do that? Also when residents r putting in orders standing around them u get asked oh get me this chart, put this chart back etc. I don't really have a huge problem doing it because I know eventually I'll be done with this year but c'mon thats not educational I'm not even getting paid lol. Thankfully never got asked to get coffee for someone unless I was personally going down to get one and I asked if anyone wanted anything. Then theres also getting stuck doing a nurses job cleaning something up after a procedure or delivery which annoys me esp when the resident doesn't say no we gotta go somewhere and me being the med student says "sure...😳" The older nurses def don't respect us at all and I've encountered several situations where I've gotten **** from them for no reason I had never even met them.

 

[JourneyAgent]

I think it's a strange propositon overall. Having no actual job to do, the question of facillitation can quickly consume all of your efforts no matter how benevolent your resident.

I would caution the OP about an unbridled desire for facillitation. Which is what is what is meant by hard work as a student. That you're reliably diligent with your patients and can actually be of service to the team. Which let's face it, is quite rarely going to be clinical. Occasionally since you spend the most time with your patients than anyone you will have the opportunity to give a bit of pertinent history that may have been left out or that you know the patient best so you can give insight into social work needs for discharge, stuff like that.

So that yes, scut is one of the useful things you can do. And I have no problem with it. Getting coffee, faxing, making phone calls, whatever. What I expect in return, and you have to learn to advocate for yourself because everyone else is too busy, is to be given the opportunity to study when the team is just waiting on results or things to make their way through the system on our patients.

That's what gets left out of their perspective on how hard we're working. That we have a shelf. And a step 2 exam to get ready for. Much of what we need to get out of a certain field is not going to happen on rounds or in the relatively small amount of patients you will carry during the rotation.

So I'm now figuring out to negotiate this space and I can tell you working hard for the team's goals is only part of it. Eventually it will be all of it. And I look forward to that aspect of being a physician rather than a student. But mistaking yourself for them at this point is a mistake. Shelf exams are tough adversaries.

 

[45408]

Prowler, is that a mix of 3rd/4th year advice or one year moreso than the other?

I was gearing it to an M3. An M4 should be more pro-active, not be told what to do very often, and actually be fairly useful. On my medicine sub-I, I did all the H&Ps and D/C summaries on my patients, called all consults, entered all orders, managed all the complicated discharges/social work, etc. I had a senior resident who was generally aware of what I was doing in the big picture, but he didn't even read through my orders, lol. He was brilliant and hard-working, but extremely swamped. As long as I didn't ask him a question about the orders, he just co-signed them en masse.

Yeah u know some of the residents will actually apologize and say "sorry to scut you out, but..." And some of the stuff is involved with patient care for example faxing for medical records (and of course dealing with the unhappy case managers who are pissed your using their fax machine), running down non-stat labs, running down to get final reads from radiology to turn pts over faster. I know some of it is necessary but using med students as the gofer every time prob counts as scut.

If it's your patient, then it's still not scut, IMO. It might not be the best use of your time, but it is useful to actually do some of these things a handful of times so you're familiar with the overall process. A lot of this is moot, at least where I am. The secretary will get medical records, labs are all sent via a tube system, and radiology reads show up online. If I need to talk to the radiologist, I'll page them myself and talk to them. If anyone actually needs to review the images with the radiologist, it's me. I know all of our radiologists, and it would be a bit insulting to them to have a student call them instead of myself, because it would imply that the radiologist's time is worth less than mine.

Also when residents r putting in orders standing around them u get asked oh get me this chart, put this chart back etc. I don't really have a huge problem doing it because I know eventually I'll be done with this year but c'mon thats not educational I'm not even getting paid lol.

Honestly, if you're standing between me and the chart rack, and I'm busy, and you're doing nothing, it really seems at all unreasonable for you to put them back in the rack? I would only do that if you were standing between me and the rack, and if you don't feel like doing it, then find something to actually do. Sit down at a computer and review your patients and any new labs/imaging/consults/etc. That's what I'm doing.

Then theres also getting stuck doing a nurses job cleaning something up after a procedure or delivery which annoys me esp when the resident doesn't say no we gotta go somewhere and me being the med student says "sure...😳" The older nurses def don't respect us at all and I've encountered several situations where I've gotten **** from them for no reason I had never even met them.

I nearly always help move the patient off the OR table. I've unfortunately established that I'm willing to help the nurses clean up a pt who **** the bed in the OR.... After I put in a central line or a chest tube, I clean up the supplies I used and dispose of all sharps. The nurse isn't your maid. Now, if you're mopping the floor, that's crap.

 

[swamprat]

If it's your patient, then it's still not scut, IMO. It might not be the best use of your time, but it is useful to actually do some of these things a handful of times so you're familiar with the overall process. A lot of this is moot, at least where I am. The secretary will get medical records, labs are all sent via a tube system, and radiology reads show up online. If I need to talk to the radiologist, I'll page them myself and talk to them. If anyone actually needs to review the images with the radiologist, it's me. I know all of our radiologists, and it would be a bit insulting to them to have a student call them instead of myself, because it would imply that the radiologist's time is worth less than mine.

Its not always my patient, however its a patient on our list. Again, scut or not I don't really mind this that much.

Honestly, if you're standing between me and the chart rack, and I'm busy, and you're doing nothing, it really seems at all unreasonable for you to put them back in the rack? I would only do that if you were standing between me and the rack, and if you don't feel like doing it, then find something to actually do. Sit down at a computer and review your patients and any new labs/imaging/consults/etc. That's what I'm doing.

Can't do that when you don't have logins for the computer system. Its not just putting charts back its getting charts back and forth, getting a blank progress note etc. You have 2 legs and can walk, its one thing if we're busy and hurrying to prepare for rounds its another thing if its middle of the day nothing to do. Again, I don't really mind it because I've come to expect it and it won't be forever.

I nearly always help move the patient off the OR table. I've unfortunately established that I'm willing to help the nurses clean up a pt who **** the bed in the OR.... After I put in a central line or a chest tube, I clean up the supplies I used and dispose of all sharps. The nurse isn't your maid. Now, if you're mopping the floor, that's crap.

I am not a maid either and I didn't do the procedure or delivery, the resident did.. someone has to clean it up and I don't see any residents doing it. And I'm not rlly talking about cleaning up the central line kit or something I'm talking about helping change the sheets or put equipment and tools away. Someone has to do it but that is part of what the nurses do at the hospitals I've been at. No not cleaning the floors but doing that kind of stuff. Last I checked I'm not training to be an RN. And this is not to downplay nurses essential role but I don't appreciate the lack of respect they show us as medical students and the lack of say we have into things unless one of our residents bail us out (which happens).

 

[da8s0859q]

I was gearing it to an M3. An M4 should be more pro-active, not be told what to do very often, and actually be fairly useful. On my medicine sub-I, I did all the H&Ps and D/C summaries on my patients, called all consults, entered all orders, managed all the complicated discharges/social work, etc. I had a senior resident who was generally aware of what I was doing in the big picture, but he didn't even read through my orders, lol. He was brilliant and hard-working, but extremely swamped. As long as I didn't ask him a question about the orders, he just co-signed them en masse.

Whoa. So did you have a lot of rotations where they were the usual relaxed M4 things to make up for that?

 

[kindasorta]

Whoa. So did you have a lot of rotations where they were the usual relaxed M4 things to make up for that?

No kidding. A 10th grader would be more useful to the team than I am as an M4.

 

[45408]

Whoa. So did you have a lot of rotations where they were the usual relaxed M4 things to make up for that?

Both of my sub-Is were quite rigorous, as they often are at my school. The rest of the year wasn't too bad, but I didn't quite think of it as the same vacation as many people do. Having a child in the middle of it was a big factor though, because they are very stressful.

 

[mimelim]

Whoa. So did you have a lot of rotations where they were the usual relaxed M4 things to make up for that?

My Sub-I's (Trauma ICU and SICU) and my surgical rotations (Trauma Surgery and Vascular Surgery as aways and Vascular and Kidney Transplant at home) were very busy. 6 months of holding the team pager, seeing all consults possible, H&Ps, etc. I think that it was as rigorous as my intern year. Paid off in spades though. LOR were great, "We prefer him to our interns when on service." Or, "No reservations, already functioning as a house officer." I also felt a lot more comfortable taking calls from nurses and sorting through basic floor calls when by myself.

 

[da8s0859q]

My Sub-I's (Trauma ICU and SICU) and my surgical rotations (Trauma Surgery and Vascular Surgery as aways and Vascular and Kidney Transplant at home) were very busy. 6 months of holding the team pager, seeing all consults possible, H&Ps, etc. I think that it was as rigorous as my intern year. Paid off in spades though. LOR were great, "We prefer him to our interns when on service." Or, "No reservations, already functioning as a house officer." I also felt a lot more comfortable taking calls from nurses and sorting through basic floor calls when by myself.

Damn. Makes me feel like a huge slacker -- my medicine sub-I and ICU months were nothing even close to this.

 

[nlax30]

It definitely varies depending on location. And now with some of the CMS "rules" I think it's going to get more difficult for students to get the usual experience that some of us had. At least at my institution they no longer allow students to write in the charts. Prior to this we would have the student start on an admit and write up the H&P which actually helped out the team on busy days. They can still go do an H&P, but it's not going in the chart and intern has to write it up anyway.

My first month of medicine was key in learning to write up a proper H&P and progress note.... not the case anymore.

 

[nlax30]

I nearly always help move the patient off the OR table. I've unfortunately established that I'm willing to help the nurses clean up a pt who **** the bed in the OR.... After I put in a central line or a chest tube, I clean up the supplies I used and dispose of all sharps. The nurse isn't your maid. Now, if you're mopping the floor, that's crap.

I've found that this sort of attitude will go a long way and it will come back around in your favor. I'm the same way with lines I do in the unit... I try and clean up my own mess. When I'm done sharps are away, dressing is on and we're ready for the CXR. I know the nurses appreciate it and in turn are willing to go the extra mile in helping me out when I need several things done to a patient.

 

[duckie99]

I've found that this sort of attitude will go a long way and it will come back around in your favor. I'm the same way with lines I do in the unit... I try and clean up my own mess. When I'm done sharps are away, dressing is on and we're ready for the CXR. I know the nurses appreciate it and in turn are willing to go the extra mile in helping me out when I need several things done to a patient.

that really doesn't sound like going out of the way to me...

And on cases when you do actually go out of the way how do you know they aren't all sitting around talking behind your back about how whipped they have you? What's to keep a few bad apples from taking advantage? Not saying you shouldn't help. But people will exploit behavior that is too kind or going way out of the way.

But, I think it is only proper to clean up your own mess. That isn't protocol? How would it be safe for a nurse to walk around 20 min later and try to find all the sharps she has no idea about while the patient is in the room with all that trash lying around? Cleaning up isn't going out of the way at all.

Finally, now that I think about it, I have never seen an attending surgeon help move a patient after a case (I have seen them help position the pt at the beginning a lot). Residents I think help at the end because there is an unwritten rule that they must stay. But I've been around private practice surgeons in the OR for a few weeks and not one of them stayed and moved the patient after they were done closing (if they didn't leave the closing for the PA/NP) and most every one of them in academics left the room as well. So obviously there is a breakdown in the "helpfulness" as surgeons move up the ladder... and IMO it only makes sense because you can't sit around for 15 minutes trying to move a patient when you have a ton of other work left to do...

 

[nlax30]

Most of the time I see nurses cleaning up the sharps and the other supplies.

I really don't care if they talk behind my back or think they have me "whipped". At least the ones I trust/like don't think that. Often they just offer to clean everything up anyway.

Otherwise we are fairly scut-free.... Don't have to transport, draw labs, fax papers, etc....

 

[Winged Scapula]

that really doesn't sound like going out of the way to me...

And on cases when you do actually go out of the way how do you know they aren't all sitting around talking behind your back about how whipped they have you? What's to keep a few bad apples from taking advantage? Not saying you shouldn't help. But people will exploit behavior that is too kind or going way out of the way.

But, I think it is only proper to clean up your own mess. That isn't protocol? How would it be safe for a nurse to walk around 20 min later and try to find all the sharps she has no idea about while the patient is in the room with all that trash lying around? Cleaning up isn't going out of the way at all.

Finally, now that I think about it, I have never seen an attending surgeon help move a patient after a case (I have seen them help position the pt at the beginning a lot). Residents I think help at the end because there is an unwritten rule that they must stay. But I've been around private practice surgeons in the OR for a few weeks and not one of them stayed and moved the patient after they were done closing (if they didn't leave the closing for the PA/NP) and most every one of them in academics left the room as well. So obviously there is a breakdown in the "helpfulness" as surgeons move up the ladder... and IMO it only makes sense because you can't sit around for 15 minutes trying to move a patient when you have a ton of other work left to do...

I always help move the patient at the end of the case; that may reflect my personality or staffing issues where there simply aren't enough people around (scrub has usually left, getting ready for my next case). I also always dispose of my own sharps and usually clean up after myself.

 

[SouthernSurgeon]

t
That isn't protocol? How would it be safe for a nurse to walk around 20 min later and try to find all the sharps she has no idea about while the patient is in the room with all that trash lying around? Cleaning up isn't going out of the way at all.

Yeah it's definitely protocol at my hospital. If you left sharps around after a procedure in the ICU or ED, you'd get written up. Probably rightfully so I would say as it's just not safe. I've had a couple of times where a nurse is helping me during the procedure and they offer to throw them out when we are done, but otherwise I do it.

Finally, now that I think about it, I have never seen an attending surgeon help move a patient after a case (I have seen them help position the pt at the beginning a lot). Residents I think help at the end because there is an unwritten rule that they must stay. But I've been around private practice surgeons in the OR for a few weeks and not one of them stayed and moved the patient after they were done closing (if they didn't leave the closing for the PA/NP) and most every one of them in academics left the room as well. So obviously there is a breakdown in the "helpfulness" as surgeons move up the ladder... and IMO it only makes sense because you can't sit around for 15 minutes trying to move a patient when you have a ton of other work left to do...

Yeah I think this is generally true. I have a couple of attendings who ALWAYS stay on principle, but for the most part they are a ghost as soon as we are closing skin. The only exception in general is any case where there is an airway concern - most of the staff stay around in those cases.

 

[ArcGurren]

I always help move the patient at the end of the case; that may reflect my personality or staffing issues where there simply aren't enough people around (scrub has usually left, getting ready for my next case). I also always dispose of my own sharps and usually clean up after myself.

Do you have students/residents working with you? At my program the residents and students were the ones who helped out with moving the patient after the surgery was over. I rarely if ever saw an attending move a patient to the bed at the end of the case for transport to the PACU (same goes for the cardiologists and GIs I've seen).

 

[ArcGurren]

1. Avoid prolonged breaks to smoke/eat/call your girlfriend/go to the bathroom at an inopportune moment.
2. See patients efficiently, document your findings as soon as possible, be thorough but not ridiculous.
3. Be on time, every time. On time means at least a few minutes early. There is rarely an excuse to be late.
4. Don't announce that you have lecture at 1pm, so you need to leave at 11:30. We all know how long it takes to get there.
5. Team has a new consult/admit? Offer to go see it.
6. Team is sitting around, looking bored? Ask to talk through a common scenario (chest pain, abd pain) or see if an attending has clinic you could do.
7. I will nearly always think it's reasonable for you to get lunch, but if there's really some sh-t flying, your education will suffer sometimes if you bail out for food, so keep a snack bar in your pocket if you can't focus on an empty stomach.
8. If you start following a patient, stick with them. If you're in doubt as to whom you should be following, ask the team. I'm never going to assign a student to a patient who's been camped out for 3 weeks on TPN.
9. If there's a conference/operation the next day, read about it. Be prepared. Know the disease/topic/patient and be able to speak intelligently about it. A 3x5 card can be very useful to remind you "Okay, 67 y/o M with hepatic flexure colon CA, plan is to do an extended R hemicolectomy, co-morbidities include diabetes, HTN. Prior abd operation is a gastric bypass."
10. Look interested. Be interested. You do not have to lie to me and say you want to do surgery, because I will try to tailor your experience to something useful, but don't sit there looking bored all day, please.
11. Know what is happening to your patients and when. If your pt is getting a CT scan to see if they need an operation/procedure, then you should not be the last person to know. You could go with the pt to the scanner or go review the images with the radiologist, so that you're the first one to know what it shows.


A few lousy residents might scut you out a lot, but if it involves seeing patients, medical decision-making, expediting patient care in an urgent situation (I'll draw blood, take a pt to the CT scanner and watch the scan, wheel them into the OR, place a Foley, review images with the radiologist, etc), or coordinating care for your patient, then it isn't scut.

I'd say this is a solid list of what "working hard" entails. As an M4 I would say it's all of these + making decisions for your patients on your own, doing the procedures on your own patients (within reason of course - an arterial line/central line/ABG with some mild supervision by someone who's done several of them is probably appropriate, a thoracentesis or chest tube for the first time, I'd think not), doing your own H&Ps/admissions, notes, and carrying multiple patients (depends on your personal comfort level IMO - on the floor I'd say 4-6 patients is good, and in the unit 2-4 patients is good).

 

[Winged Scapula]

Do you have students/residents working with you? At my program the residents and students were the ones who helped out with moving the patient after the surgery was over. I rarely if ever saw an attending move a patient to the bed at the end of the case for transport to the PACU (same goes for the cardiologists and GIs I've seen).

Most of the time but not every month.

If I do, then yes, they are usually doing the moving while I am dictating (or now the new rule is I can't leave the OR until my post-op EMR note is done 🙄 ). Sometimes I will send the student/resident over to Pre-Op to see the next patient so we can get things moving. I rarely have very obese patients but in those cases I might hang back to add another pair of hands for moving.

I tend to hang around until the ETT is removed and the patient out the door. I've been burned too many times telling the family, "everything is fine" only to go to the PACU finding the patient reintubated.

 

[duckie99]

I'd say this is a solid list of what "working hard" entails. As an M4 I would say it's all of these + making decisions for your patients on your own, doing the procedures on your own patients (within reason of course - an arterial line/central line/ABG with some mild supervision by someone who's done several of them is probably appropriate, a thoracentesis or chest tube for the first time, I'd think not), doing your own H&Ps/admissions, notes, and carrying multiple patients (depends on your personal comfort level IMO - on the floor I'd say 4-6 patients is good, and in the unit 2-4 patients is good).

... I think you are overestimating an M4's abilities. "making decisions" - uh... we have no power. We should be knowledge and suggest things to do with confidence but we are not the ones actually making the decision. "doing procedures" - usually having a student do it makes things move much slower for the team and resident because students should be supervised (not saying the student shouldn't ask though and do it if allowed).

- doing your own notes and carrying multiple patients is something I would expect any medical student to do. However I think 4 patients in the ICU is too much. 2 is probably a good number for the first go-around. Most students don't have ICU rotations though.

 

[volvo2]

1. Avoid prolonged breaks to smoke/eat/call your girlfriend/go to the bathroom at an inopportune moment.
2. See patients efficiently, document your findings as soon as possible, be thorough but not ridiculous.
3. Be on time, every time. On time means at least a few minutes early. There is rarely an excuse to be late.
4. Don't announce that you have lecture at 1pm, so you need to leave at 11:30. We all know how long it takes to get there.
5. Team has a new consult/admit? Offer to go see it.
6. Team is sitting around, looking bored? Ask to talk through a common scenario (chest pain, abd pain) or see if an attending has clinic you could do.
7. I will nearly always think it's reasonable for you to get lunch, but if there's really some sh-t flying, your education will suffer sometimes if you bail out for food, so keep a snack bar in your pocket if you can't focus on an empty stomach.
8. If you start following a patient, stick with them. If you're in doubt as to whom you should be following, ask the team. I'm never going to assign a student to a patient who's been camped out for 3 weeks on TPN.
9. If there's a conference/operation the next day, read about it. Be prepared. Know the disease/topic/patient and be able to speak intelligently about it. A 3x5 card can be very useful to remind you "Okay, 67 y/o M with hepatic flexure colon CA, plan is to do an extended R hemicolectomy, co-morbidities include diabetes, HTN. Prior abd operation is a gastric bypass."
10. Look interested. Be interested. You do not have to lie to me and say you want to do surgery, because I will try to tailor your experience to something useful, but don't sit there looking bored all day, please.
11. Know what is happening to your patients and when. If your pt is getting a CT scan to see if they need an operation/procedure, then you should not be the last person to know. You could go with the pt to the scanner or go review the images with the radiologist, so that you're the first one to know what it shows.


A few lousy residents might scut you out a lot, but if it involves seeing patients, medical decision-making, expediting patient care in an urgent situation (I'll draw blood, take a pt to the CT scanner and watch the scan, wheel them into the OR, place a Foley, review images with the radiologist, etc), or coordinating care for your patient, then it isn't scut.

The above list of eleven happen to be good guidelines for me. It was nice of you to take the time to give the OPs post some thought and then post your own really helpful advice. Thank you.

 

[evilbooyaa]

It definitely varies depending on location. And now with some of the CMS "rules" I think it's going to get more difficult for students to get the usual experience that some of us had. At least at my institution they no longer allow students to write in the charts. Prior to this we would have the student start on an admit and write up the H&P which actually helped out the team on busy days. They can still go do an H&P, but it's not going in the chart and intern has to write it up anyway.

My first month of medicine was key in learning to write up a proper H&P and progress note.... not the case anymore.

The bolded is garbage. Student notes should go in the chart so they know for sure how to write a damn note when it comes to being an intern and having to put notes in the chart. If they don't go into the chart, the motivation to them drops, and then feedback on those notes is lost. On all my rotations so far (except outpatient IM) I have had my own patients that I wrote notes for and put in the chart. The only exception to this is Trauma ICU. The junior resident wants me to see the most interesting cases, and that may mean pairing me with an intern. If I'm with an intern (who is learning the trauma ICU note process his/herself), they want to write their own note from scratch. If I'm with the junior resident, I fill out all relevant lab values and basic information, but leave assessment and plan blank (so the junior can fill it out and sign it). I don't like it compared to previous services, but it is what it is. Once I get onto a general surgery team in 2.5 weeks, I will be putting my own notes back into the patient's chart (and have a R2-R5 writing their own note) on top of it.

 

[nlax30]

Well I agree and try to get around by still having students write notes on separate paper that's not going to be part of the medical record.

With CMS billing regulations the student can only really document things such as ROS/PMH/Fam hx as part of an E/M billed service. Beyond that we can't use a student's progress note and then just add our own assessment/plan and just refer to their exam/labs/etc.... At least not technically according to CMS billing guidelines. And hospitals and paying closer attention to these things.

We can certainly have students still write their own notes and we can go over them later and compare to the intern/resident note, but it can't be used as part of the medical record.

http://www.cms.gov/Outreach-and-Edu...roducts/downloads/gdelinesteachgresfctsht.pdf

 

[duckie99]

The bolded is garbage. Student notes should go in the chart so they know for sure how to write a damn note when it comes to being an intern and having to put notes in the chart. If they don't go into the chart, the motivation to them drops, and then feedback on those notes is lost. On all my rotations so far (except outpatient IM) I have had my own patients that I wrote notes for and put in the chart. The only exception to this is Trauma ICU. The junior resident wants me to see the most interesting cases, and that may mean pairing me with an intern. If I'm with an intern (who is learning the trauma ICU note process his/herself), they want to write their own note from scratch. If I'm with the junior resident, I fill out all relevant lab values and basic information, but leave assessment and plan blank (so the junior can fill it out and sign it). I don't like it compared to previous services, but it is what it is. Once I get onto a general surgery team in 2.5 weeks, I will be putting my own notes back into the patient's chart (and have a R2-R5 writing their own note) on top of it.

I think the hardest thing for student to accept (as it was for me initially) is that they are not necessary for patient care, no one wants to see the student's note, and that the student is there solely to learn. A student is not on a rotation to work. It is not a job. However, obviously the best way to learn is to go see patients and write notes for themselves and have a resident/intern/attending review them.

But students honestly need to get over themselves. This is hard because M3s are so used to be the smartest people around and are all of the sudden thrown into a situation where they are the dumbest. It is what it is. BTW when you are a M4 you will do everything in your power to avoid writing a note (it's just more work and you know it's pretty useless to everyone involved).

So if a EMR allows a student note to be put in then that it is appropriate for the student to put in a note in conjunction with the resident. But just realize that no one will go off a student's note to manage the patient. And if a EMR does not allow it, a student should write a paper note and discuss with their intern/resident their note and plan. The only way to get good at notes is to write them and have them reviewed.

 

[MedPR]

1. Avoid prolonged breaks to smoke/eat/call your girlfriend/go to the bathroom at an inopportune moment.
2. See patients efficiently, document your findings as soon as possible, be thorough but not ridiculous.
3. Be on time, every time. On time means at least a few minutes early. There is rarely an excuse to be late.
4. Don't announce that you have lecture at 1pm, so you need to leave at 11:30. We all know how long it takes to get there.
5. Team has a new consult/admit? Offer to go see it.
6. Team is sitting around, looking bored? Ask to talk through a common scenario (chest pain, abd pain) or see if an attending has clinic you could do.
7. I will nearly always think it's reasonable for you to get lunch, but if there's really some sh-t flying, your education will suffer sometimes if you bail out for food, so keep a snack bar in your pocket if you can't focus on an empty stomach.
8. If you start following a patient, stick with them. If you're in doubt as to whom you should be following, ask the team. I'm never going to assign a student to a patient who's been camped out for 3 weeks on TPN.
9. If there's a conference/operation the next day, read about it. Be prepared. Know the disease/topic/patient and be able to speak intelligently about it. A 3x5 card can be very useful to remind you "Okay, 67 y/o M with hepatic flexure colon CA, plan is to do an extended R hemicolectomy, co-morbidities include diabetes, HTN. Prior abd operation is a gastric bypass."
10. Look interested. Be interested. You do not have to lie to me and say you want to do surgery, because I will try to tailor your experience to something useful, but don't sit there looking bored all day, please.
11. Know what is happening to your patients and when. If your pt is getting a CT scan to see if they need an operation/procedure, then you should not be the last person to know. You could go with the pt to the scanner or go review the images with the radiologist, so that you're the first one to know what it shows.


A few lousy residents might scut you out a lot, but if it involves seeing patients, medical decision-making, expediting patient care in an urgent situation (I'll draw blood, take a pt to the CT scanner and watch the scan, wheel them into the OR, place a Foley, review images with the radiologist, etc), or coordinating care for your patient, then it isn't scut.

How do you volunteer for stuff without appearing like an ass kisser?

 

[Ilovewater]

How do you volunteer for stuff without appearing like an ass kisser?

1) You can ask your classmates if they want a mini-lecture from the intern/resident/attending before you pitch the idea as a group.

2) You can just say that you don't know a particular subject well and ask if the intern/resident/attending wouldn't mind clarifying some stuff.

 

[evilbooyaa]

I think the hardest thing for student to accept (as it was for me initially) is that they are not necessary for patient care, no one wants to see the student's note, and that the student is there solely to learn. A student is not on a rotation to work. It is not a job. However, obviously the best way to learn is to go see patients and write notes for themselves and have a resident/intern/attending review them.

But students honestly need to get over themselves. This is hard because M3s are so used to be the smartest people around and are all of the sudden thrown into a situation where they are the dumbest. It is what it is. BTW when you are a M4 you will do everything in your power to avoid writing a note (it's just more work and you know it's pretty useless to everyone involved).

So if a EMR allows a student note to be put in then that it is appropriate for the student to put in a note in conjunction with the resident. But just realize that no one will go off a student's note to manage the patient. And if a EMR does not allow it, a student should write a paper note and discuss with their intern/resident their note and plan. The only way to get good at notes is to write them and have them reviewed.

Agreed with all your points.

Just as an update, I'm on a general surgery service now and I write notes on my own patients, that the interns co-sign on (all they write is "I have independently blah blah and agree with the plan" and then add whatever clarifications I'm not sure on.

 

[JJMrK]

Maybe more important/equally important as working hard, don't be annoying:
- No asking questions just to show you know the answer.
- Try to figure out the answer for yourself before you ask a question.
- If you have a non-urgent question and it's stressful on the service, write it down and ask later.
- Not everything is going to go exactly according to your syllabus. I have seen way too many people say, "but it says here...". Just let it go.
- Be selective about the issues you bring up on rounds, figure out what you can just tell the resident later.
- Pay attention to how the residents present. Not everything in the note needs to be said out loud, and usually no one wants to listen to you drone on and on about a patient's physical exam findings.
- Don't correct people unless it matters.
- You probably shouldn't be asking questions at grand rounds. Definitely not the first day.
- Medical students aren't really that important. Don't act like you are.

 

[nlax30]

The bolded is garbage. Student notes should go in the chart so they know for sure how to write a damn note when it comes to being an intern and having to put notes in the chart. If they don't go into the chart, the motivation to them drops, and then feedback on those notes is lost. On all my rotations so far (except outpatient IM) I have had my own patients that I wrote notes for and put in the chart. The only exception to this is Trauma ICU. The junior resident wants me to see the most interesting cases, and that may mean pairing me with an intern. If I'm with an intern (who is learning the trauma ICU note process his/herself), they want to write their own note from scratch. If I'm with the junior resident, I fill out all relevant lab values and basic information, but leave assessment and plan blank (so the junior can fill it out and sign it). I don't like it compared to previous services, but it is what it is. Once I get onto a general surgery team in 2.5 weeks, I will be putting my own notes back into the patient's chart (and have a R2-R5 writing their own note) on top of it.

You and I may not like it but it's going to change at more and more places as they start becoming more strict with CMS rules/regulations.

They may not effect you now but you will start to deal with them more during your residency and physician career.