The dismal state of surgical education

[filter07]

Would anyone like to comment on the sorry state of surgical education these days? Maybe I'm getting old and senile, but I remember a time when students learned some practical skills in their surgery rotation. Like how to write a note, present efficiently, assess a wound, change a dressing, do a physical exam, identify basic post operative complications.

I have a feeling that students these days have almost no clue how to do these basic things we take for granted. I think the practical knowledge of surgery is routinely dismissed for book knowledge. I feel that many are only studying for the shelf.

Now don't get me wrong, I tried to take some time away to study for the shelf too. But I also read surgical recall to not look completely clueless for day-to-day survival. I read before every case, and I checked on my patients post operatively. Between the other student and me, we wrote notes for the entire service. Nowadays it seems the students don't even have a book in their pockets (let alone dressing supplies). They just drift along like they're in a water ride at Disneyland, waiting for the tour guide to show them something interesting.

Please tell me I'm just too old to remember how things really were back then, and my perspective is skewed. Because otherwise I fear for the future of our profession. I don't want our residents to consult the wound team to remove a dressing.

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[Wolverines83]

So with regards to books remember this: they probably have the book on their phone/tablet.

I gotta say, I had an old school attending who taught me all of the stuff you're taking about.

The shelf exams definitely take away from education but what can you do in this era of standardization?

 

[filter07]

I asked the residents once why these students don't know where to get dressing supplies or how to change wounds. They admitted they were being too nice to them. Yes, it's everyone's fault, not just the students. The students will play down to their expectations. The expectations have become so low that if you just show up most days with a smile, you are going to be fine.

The year before me, the 3rd year students had to take overnight call. Then in my year, overnight call was not "educational" enough, so we stayed until midnight. Now the students "work" 1 weekend a month, which really means they walk around with the team with their hands in their pockets for 30 minutes and go home soon afterwards. Because if you keep them to do a dressing, they are being scutted and we are being abusive, and wasting their time.

Once students notes couldn't just be co-signed, I feel like less and less things can be done by them. When less and less can be useful, there is less incentive to teach them to do something. And when they do less and less, learned helplessness sets in for the residents and attendings and we just pass them along with honors and make it everyone else's problem.

 

[drcrispmd]

My surgery rotation was summer of 2009. We had to see all the patients on the service, do all dressing changes, write notes, always have supplies in our pockets, scrub on all cases, do all post op and pre op notes, go to all consults with the intern, get labs for the residents when they were available, etc. we had to do overnight call q4 (some weeks were q3 when we had student doing their SICU week). That was 12 weeks. As students we were putting in about 100 hours a week (because duty hours do not apply to students). The residency I did my rotation with is longer around. It was a miserable 12 weeks but it prepared me for all the other rotations (it was my first one of 3rd year). I also felt more prepared for long hours of residency because it was not the first time I was doing it. Just since then, it does seem like 3rd and 4th year have gotten too easy. Scut work is for students. It help you learn. I should say what is now considered scut work. I had an intern that felt he was doing too much a it work by following up on patients in the afternoon of other resident's patients because they had clinic. Now if the residents are asking them to go pick up their laundry or get them something to eat when nothing is going on, that is different.

 

[bubsy84]

Ah, yes, the "kids these days are crap" gripe...

Most of us will gladly work hard if some modicum of interest is shown in our education. If students aren't performing up to your expectations, TEACH US! Too often I would hear residents complain about their students... but then never give them any feedback about how to improve. Remember that med students are in completely new settings almost every 4 weeks or so (+/-, depending on the situation), and a great number of the things that you take for granted are completely unknown to them.

Surgery is the rotation where I received the lowest level of interest from faculty and residents in actually helping educate me. Yes, I get that you're busy. Yes, I get that there are sick patients. But if you don't want educating students to be a part of your job then you shouldn't work in that type of practice setting.

 

[filter07]

I think education for surgery residents is poor too and I feel that I am also a product of that inferior education. The era of the 5 doing a colon with a 3 is coming to a close. I would do some, but the attending would be in the room and watching and commenting. That's not really a 5 doing a case with a 3. Maybe it's because it was lap, I dunno. When you do a case really by yourself you struggle and you wonder why it wasn't as easy as the time you did it with the attending. Then you learn the nuances of exposures and the other little things they did. Just everything up and down the chain in surgical education is worse, other than book learning, which is phenomenal now with all the youtube resources.

 

[filter07]

Bubsy84, I agree with you. Most of the problem is not the students themselves. Like I said, people play down to their expectations. It's an absurd situation, because the residents and attendings feel that the medical students are too empowered to complain, yet most of the medical students still feel a ton of anxiety and fear over their surgery rotation. Students are being pulled away to do surgical simulation and missing out on big cases. It's not everyday that we do open AAA in VS anymore, and where were the med students? Going to a 4th year planning session... in November!

I have no idea what goes on during the 1st/2nd years, but we've had people complain that the bike racks weren't close enough to the lecture halls. Or that the bike rack that was there didn't accommodate enough bikes. These guys then go into their clinical rotations where they are repeated told not to do scut, warned about abuse, empowered to write feedback. I mean most of that is great, but what we're seeing now are the unintended consequences. We feel really confident but we aren't as good. Somewhere along the way, they will run into someone like me who gives criticism to make them better. Most will respond well, some won't and will run to their keyboards about how their feelings were hurt.

The residents have a different problem. Quality metrics and increased scrutiny means the attendings are always around. When the attendings are around, the less you are able to struggle and problem-solve. The less you do that, the less you can bail yourself out.

When I was an intern, the fellow came in and did 90% of the operation on his own while the attending got there. Now after GS, I can't do a whipple on my own. The 2nd years now can't put in a subclavian line or chest tube on their own anymore. The third year students don't even know what a wet to dry dressing is. It just gets worse and worse.

 

[VisionaryTics]

Bubsy84, I agree with you. Most of the problem is not the students themselves. Like I said, people play down to their expectations. It's an absurd situation, because the residents and attendings feel that the medical students are too empowered to complain, yet most of the medical students still feel a ton of anxiety and fear over their surgery rotation. Students are being pulled away to do surgical simulation and missing out on big cases. It's not everyday that we do open AAA in VS anymore, and where were the med students? Going to a 4th year planning session... in November!

I have no idea what goes on during the 1st/2nd years, but we've had people complain that the bike racks weren't close enough to the lecture halls. Or that the bike rack that was there didn't accommodate enough bikes. These guys then go into their clinical rotations where they are repeated told not to do scut, warned about abuse, empowered to write feedback. I mean most of that is great, but what we're seeing now are the unintended consequences. We feel really confident but we aren't as good. Somewhere along the way, they will run into someone like me who gives criticism to make their better. Most respond well, some don't and run to their keyboards about how their feelings were hurt.

The residents have a different problem. Quality metrics and increased scrutiny means the attendings are always around. When the attendings are around, the less you are able to struggle and problem-solve. The less you do that, the less you can bail yourself out.

When I was an intern, the fellow came in and did 90% of the operation on his own while the attending got there. Now after GS, I can't do a whipple on my own. The 2nd years now can't put in a subclavian line or chest tube on their own anymore. The third year students don't even know what a wet to dry dressing is. It just gets worse and worse.

I think the big issue is the increasing requirement for oversight and the lack of responsibility given to med students as a result. Med students can't write notes or put in orders. Christ, a local residency program got an ACGME infraction for letting a subintern close a skin incision with no resident in the room. As a result, the expectations are zero and most medical students will simply meet expectations. They aren't going to come in and pre-round if the intern has to do it himself anyway or stay for evening rounds when they'll just be standing in the corner.

I'm an intern who was gung-ho about surgery as a med student, and came out of med school knowing basic surgical skills (suturing, wound care, basic peri-operative care, some faculty with central venous and arterial line insertion). But I worked harder than 98% of other med students to get those experiences. I rotated at the busiest M3 clerkship sites for general surgery and OB/gyn and used all my elective time for surgical subspecialties. As a 4th year, I used all my elective time on either away rotations in ENT or surgical critical care (I did a month each in trauma, burns, and SICU). And I came into internship still feeling underprepared.

Most medical students will do the requirements of their gen surg clerkship and nothing else. At my hospital, M3s do 2 weeks of general surgery, 1 week of trauma, 1 week of pathology/radiology, 1 week of anesthesiology, and the remainder on subspecialties. They don't round or see patients peri-operatively. They aren't required to be anywhere at any given point, and I usually see them hanging out in the lounge. They have 2-3 hours of lectures per day (6-7am, and then some in the afternoon). They come to whatever cases they feel like. It's November, and I can actually think of only twice when an M3 came into an OR I was in.

You think these med students will learn anything? No. They'll probably do well on the shelf, but they'll have zero practical knowledge or skills.

On the other hand, our subinterns on ENT mostly work very hard. The good ones come in and pre-round, get the wound supplies ready, know the patients on the service, stay for evening rounds, present patients on the floor and in clinic. But they're self-selecting.

I do think this problem will get worse and worse. I just struggle to see how to change the trajectory of things.

 

[funshi baba]

i'm sure worse has been said about us by the older generation too. I constantly hear from older surgeon how they all functioned essentially has an attending when they were 5s with attending in the call room or at home. How the only regret they had was missing cases becuase they took call every other night instead of every night.
I have come to a certain conclusion, we the new generation surgeons are at a disadvantage but it really is not the same playing filed as it was 30years ago. there is a **** ton more to learn now than there was 30years ago. But i do aspire to have the same confidence and technical know how has the older surgeons and for sure i know i'm or will be more technologically advanced.

regarding the medical student comments, i strongly believe it is completely dependent on residents and attending to show interested in these kids. I really cant lay any blame in the door step of a MS3. No offense, but they are the most educated clueless medical personnel you will ever encounter. yes, some of those kids can be borderline bastards sometimes but it is our responsbility to teach them whether they look interested or not. teach them first and decicde if the extra effort is worth it. If they do something wrong, scold them but make sure you get a teaching point in. My med students take a weekned call and round half another weeknd and get one free weekned since they are here for only 3weeks.
We were thought by the older generation even when we were ******ed. And yes, trust me everyone of us has had many ******ed moments and they still took the time to point us in the right direction; how ever unhealthy it might have been.

TEACH, even when they look uninterested, it goes a long way.

 

[SLUser11]

Would anyone like to comment on the sorry state of surgical education these days? Maybe I'm getting old and senile....

I promise that this same complaint was raised against you when you were a medical student. Medicine is constantly evolving, and some aspects suffer while others improve. During this evolution, the gray-hairs always have fond memories of their own performance in "a better time."

The current approach to medical student education is much more student-centric: They are not there to fill a role for you, but to receive exposure to surgery and have a rich, diverse experience.....this means shorter rotations with more electives, less call, less service in general, etc. On the flipside, it also means a more universal, streamlined curriculum with newer teaching practices (flipped classrooms, podcasts, etc), better preparation for the shelf exam, and built-in protection against student abuse.

The above paragraph sounds cute, but the unintended consequences include:
1. A very robust sense of entitlement among students
2. A complete lack of understanding or experience for anything unpleasant (all things that are not fun=scut)
3. Undeserved feelings of adequacy due to lack of negative (and meaningful) feedback
4. Inability to overcome obstacles with a complete collapse anytime something goes wrong
5. Worst of all, general apathy from residents and attendings toward student education (they see them for smaller periods of time, during which the student appears disinterested, is not allowed to demonstrate knowledge or ability, and is constantly having to leave the clinical realm for lectures, etc).


If you are now an attending, you have plenty of power to enact change. Talk to your clerkship director and see if you can serve a role for him/her....CDs are typically looking for help. Ask why certain things are the way that they are, etc.

When you're with students, give them your expectations up-front (e.g. tell them that when scrubbed with you, they will be expected to know the anatomy, the basic steps of the case, and the pathophysiology of the disease you're treating.....THEN HOLD THEM TO IT!). Let them know that you believe IT"S NOT SCUT UNTIL IT'S OLD HAT! If they've never helped move a patient, or place a foley, or whatever, then they're not above it.

It's a start....

 

[vhawk]

Very good post. I find it very rewarding to work with the med students, and I'm in a program that I'm sure makes most of your schools look like a gulag when it comes to coddling them. But I'm constantly frustrated in the ****ty attitude that my coresidents and attendings take towards the med students....and then they dont DO anything. They treat them with complete apathy and disdain, and then complain that the students dont work hard, and they cant ask them to do anything. There is this mythical fear of being "called into the office" to be yelled at for scutting out a med student...but mythical is exactly what that is. I hold the students to a much higher standard than most of my coresidents, I "scut them out" constantly, if by that we mean expect them to do dressing changes, expect them to follow up on labs, expect them to place foleys and help transfer patients. I also pimp them more frequently and more aggressively than anyone else. And you know what? I get the best evaluations of anyone in my program. I dont mean that as a brag, obviously, because its a stupid thing to brag about (though I do take some small amount of pride in it). I mean it as a way of saying that this fear of being reprimanded for being harsh on the students is unfounded.

The poster above who said "perform down to their expectations" is exactly right. And I think that a very large part of this attitude from residents/attendings towards the students is that it justifies their laziness. It is work, it is effort to go out of your way to include the students. Thats really whats changed. Before, it was possible for the students to legitimately make your life a little easier, by writing notes and scripts and admission orders and all that stuff. When they could make your life easier, it was easier for residents to include them and teach. Now the regulations make it hard if not impossible for them to actually make my life easier. The time I give them will not be immediately recouped. So for those who dont wanna put in the effort, they cling to this idea that "Oh man I totally would teach them but they are just gonna complain, so THATS why I ignore them, put in minimum effort and just focus on my own responsibilities."

 

[KinasePro]

Hmm, interesting thread. The med student experience at my school is pretty different from what OP and others have described. We get "scutted out" a bit every day, take overnight call, dictate clinic notes, occasionally get yelled at, and are thoroughly pimped into oblivion during a notorious oral exam at the end of our rotation...... but this is in exchange for the opportunity to close the skin, do basic lump and bump excisions from skin-to-skin, sew lacs in the trauma bay, etc...

And wouldn't you know, our surgery rotation is by far the most beloved clerkship -- even the derm and radiology folks generally enjoy it. I think students will put up with the intensity, criticism, and "scut" if the faculty appear to give a damn, and honestly I think our faculty really do give a damn. They still seem to take pride in the product of our medical school, and it creates a lot respect for surgeons (and by extension, surgical residents) among the students at my school. That said, if we didn't have a busy county and large VA hospital to provide hands-on experience, I'm sure there would be much more apathy from the students.

 

[Petypet]

Current med student on surgery and I am loving it, and was told from the PD my goal is to get as much exposure as possible, not to function as a member of the team. See the daily ins/outs of residents and attendings so that I can make a responsible decision about my specialty. Everything I do is to get exposure to what it is like to be a general surgeon. (This is not saying we aren't supposed to do scut, but rather do things once or twice for the exposure for educational purposes). Generally regarding dressings, notes, logs, procedures, whatever, its to see one, do a few (dressing changes, foleys, etc), and move on.

Regarding order/notes/etc, nothing counts for the medical record at my institution and those are just done for "educational experience". Docs can't sign or amend our notes, thus, I write a note, a resident may or may not (usually not) look at it, and may or may not give me feedback. Thus, what motivation is it for a resident to have me do those things, if they don't help them see more patients or move along faster. It actually takes them more time for me to write a note, look over my note, and give me feedback. Honestly, I wish I had more chances to have increased responsibility but its the system we are on.

From my n= 1 experience, so much of my experience is resident driven and there is no motivation for them to do anything for me. It is strictly based on their personality or desire to teach. Every rotation thusfar, I have had residents say "go home because I am just going to write notes and there is nothing educational for you here". Instead of staying around extra 5 hours to hope to do something, they just send me home. I think this is the state of medical education, not just specific to surgery. This comes from the top down, not from the bottom up. We don't know a different system, rather we are coming into this system as it exists.

Being a non-trad medical student, I certainly see a sense of entitlement among the 90's generation, but I also see a lot of students that want to work hard. Certainly there are the wallflowers that wear the minimum amount of flare, but in a lot of circumstances residents and faculty push us out the door to "study for boards/shelf exams". If I were told, go do xyz procedure, write 10 notes a day, you have 10 days of call in this 30 day rotation, whatever, it would get done. I may b*tch just like the older generation did, but stuff would get done. But when I'm told, go home and go study, that makes the system look lazy and then the older generation calls us soft, uncaring, undevoted, etc.

 

[SplenoMegastar]

I only saw 3 stand-out slackers on surgery out of maybe 15 students who overlapped with me, so I'm a little surprised because I assumed surgery was accepted to be a rotation where you are expected to work hard everywhere. At my school, even students who don't want to go into surgery get vitals for the list in the morning, do POP checks/POP notes, and put notes in charts (but generally don't write them). It's just expected. And they know that interns don't really have time to teach, so they don't expect teaching "in return". Students who want to go into surgery just write the notes and the intern reads them thoroughly and signs them. I'm generally anti-fraud but it's not that hard to buy the kind of pen your intern uses and just hand them the note, but this obviously only works with paper notes. We also tended to stay to do the later POP checks/POP notes to save the night crew time and have all the supplies needed for dressings on rounds (only changed them myself when I got the OK via text - maybe I'm timid). There were a few lazy exceptions (who were also the ones complaining about not getting taught), but I felt like the chiefs took time to teach me because I was doing stuff to help the interns and paying enough attention so that it didn't have to be re-done. And I'm not really an exceptional student in general which means I was not drawing from some advanced skill set. Maybe not all schools have this culture, but I think that since our clinical evals are worth half of our grade, it's sort of hard to get anything above a pass (and very easy to get a low pass) if you don't make an effort to help the team. From what other people have been telling me about their own grades, acing the shelf and the OSCE is not enough to do well in the rotation if everyone hates seeing your face, so I'd imagine even people who didn't really have an interest tried to be reasonably useful. Also, everyone was required to take overnight call once a week.

 

[SLUser11]

It's nice to see students here voicing their still-positive experiences and still-intact work ethics. However, just to play devil's advocate, I must point out that your impression of how things are going at your institution, and how students are performing, may differ drastically from what residents and attendings voice about you (and the rotation) behind closed doors.

We all complain about the "current state" of education, but it is likely that if we found these horrible, entitled, lazy students decribed earlier in the thread and asked them how things were going, they would be impressed with their own performance on surgery, and they would perceive the rotation as hard and "old school."

Thoughts?

 

[Petypet]

It's nice to see students here voicing their still-positive experiences and still-intact work ethics. However, just to play devil's advocate, I must point out that your impression of how things are going at your institution, and how students are performing, may differ drastically from what residents and attendings voice about you (and the rotation) behind closed doors.

Besides hurting feelings, why not bring these to the forefront. What stops the residents/attendings from giving us constructive criticism rather than sugar coating stuff. We don't build character or learn lessons by being hand held and sugar coated the entire way. Certainly I am in the minority, but I truely feel like I am not being pushed enough and even as a non-trad w/ post graduate education I don't know how I do more without being a nag. It is a super fine line between helping and wanting to learn and being a PITA. For example, my IM rotation I worked maybe 30-35 hours per week and told "go home and study, I'm not trying to trick you". How is this an accurate representation of my skills and what IM is like in residency and beyond. Then my evaluation came from an attending I had no interaction with. I know many of my colleagues have shared similar sentiments with many rotations, surgery included. It seems like for evaluations its all about impressing the right person on the right day.

From my n = 1 point of view, seems like the attendings need to be more involved with curriculum development, since if people aren't meeting expectations either those expectations aren't clear or students aren't prepared enough to meet said expectations. How? Who knows since people are already pulled in too many directions and not getting compensated for it.

 

[KnuxNole]

Besides hurting feelings, why not bring these to the forefront. What stops the residents/attendings from giving us constructive criticism rather than sugar coating stuff. We don't build character or learn lessons by being hand held and sugar coated the entire way. Certainly I am in the minority, but I truely feel like I am not being pushed enough and even as a non-trad w/ post graduate education I don't know how I do more without being a nag. It is a super fine line between helping and wanting to learn and being a PITA. For example, my IM rotation I worked maybe 30-35 hours per week and told "go home and study, I'm not trying to trick you". How is this an accurate representation of my skills and what IM is like in residency and beyond. Then my evaluation came from an attending I had no interaction with. I know many of my colleagues have shared similar sentiments with many rotations, surgery included. It seems like for evaluations its all about impressing the right person on the right day.

From my n = 1 point of view, seems like the attendings need to be more involved with curriculum development, since if people aren't meeting expectations either those expectations aren't clear or students aren't prepared enough to meet said expectations. How? Who knows since people are already pulled in too many directions and not getting compensated for it.

The thing is,some students hate hearing any negative feedback. Some, like you, will grow from it. Others, will stick their hands in their fingers, go "LALALALA" and think "OMG, that person is so mean, but whatever, I'm still awesome!", and thus grow resentment and do less work/look less interested as a result...

 

[SplenoMegastar]

It's nice to see students here voicing their still-positive experiences and still-intact work ethics. However, just to play devil's advocate, I must point out that your impression of how things are going at your institution, and how students are performing, may differ drastically from what residents and attendings voice about you (and the rotation) behind closed doors.

We all complain about the "current state" of education, but it is likely that if we found these horrible, entitled, lazy students decribed earlier in the thread and asked them how things were going, they would be impressed with their own performance on surgery, and they would perceive the rotation as hard and "old school."

Thoughts?

I would not describe anything about my current fluffy life as a med student as hard. I personally got one bad eval during surgery (deserved - I couldn't stomach the guy and was too dumb to fake it better but never did anything blatant. Please believe me when I tell you that he's the prelim version of the entitled med student archetype - literally whining like a child to sign out at 5:50 before just asking other interns to sign out for him, coming in at noon because of allergies and then taking 45 minutes for lunch) but my eval comments on that rotation were more enthusiastic, even compared to other rotations where I had honors clinical evals. I certainly hope it was real, because I'm going into surgery, so it doesn't serve anyone well to just make up a bunch of nice stuff about me. I guess that's my point. Why not just give formal or informal feedback that reflects what the student isn't getting right or working hard enough at? I'm sure some of the students doing the bare minimum thought they were crushing it, but I think they generally get bland evals. Isn't that all the justice anyone can really expect? And yeah, I do get the sense that every resident thinks they were the best student, and every attending thinks they were the best resident but I have heard comments like that in all my rotations so far. People love themselves.

 

[vhawk]

The thing is,some students hate hearing any negative feedback. Some, like you, will grow from it. Others, will stick their hands in their fingers, go "LALALALA" and think "OMG, that person is so mean, but whatever, I'm still awesome!", and thus grow resentment and do less work/look less interested as a result...

The REAL "thing is" giving negative feedback is hard, its uncomfortable, its awkward, and most people dont like doing it. And in this case, it has no real benefit for the person giving the feedback, because the student is on for a short time, and any improvement they make isnt gonna help me. So residents dont WANT to do it. But they know they are supposed to, so to solve that little issue of cognitive dissonance, they convince themselves that the reason they dont give negative feedback is due to external factors out of their control, like "those students wont want to hear it anyway" or "I will get yelled at if I am too mean to them."

 

[TallScrubs]

Here's how my surgical rotation was last year:

Students were expected to be in early (before the residents) and round on whatever patients were assigned to them, write notes which were to be cosigned, then pre-op people prior to surgery. We didn't always have time for teaching rounds, but the residents made a sincere effort to give us those at least twice per week, with students presenting patients and being pimped. Something you didn't know? That's ok, give us a five minute presentation tomorrow. When there were things that we sucked at, guess what? That's ok too, here's how you fix that so we expect you to be better at that tomorrow....no excuses then.

We were expected to be in the OR as much as possible...and in the sliver of time in between, go check on your other patients (labs, new imaging, consults, etc). We were expected to present an "interesting" (they never were) case at grand rounds where the whole program would pimp. It was a fantastic rotation and i'm glad we were given responsibility and expected to contribute. In return, residents made time to teach.

I've heard of my classmates going through various rotations and bitching about "scut work" and then rattle off several things that, frankly, should be done by medical students. You're part of the team...do whatever you can for your patients and whatever you can to help your team out. You know what? No, do [insert task here] may not be the MOST educational thing ever, or educational at all, but if it frees up my residents to teach me later....you catch my drift

I think that everyone needs to put in more effort. I too have seen residents who have absolute disdain for students (way beyond apathy) and that seems so irrational to me. Like there was nobody there to teach them or help them as a student?

 

[KinasePro]

It's nice to see students here voicing their still-positive experiences and still-intact work ethics. However, just to play devil's advocate, I must point out that your impression of how things are going at your institution, and how students are performing, may differ drastically from what residents and attendings voice about you (and the rotation) behind closed doors.

We all complain about the "current state" of education, but it is likely that if we found these horrible, entitled, lazy students decribed earlier in the thread and asked them how things were going, they would be impressed with their own performance on surgery, and they would perceive the rotation as hard and "old school."

Thoughts?

I think you have a point, but in my experience the "horrible, entitled, lazy students" that OP describes are pretty easy to spot. I don't think we have many of them in our surgery clerkships, because they not infrequently asked to repeat the clerkship. I hope I'm not one of them, and I think I could give evidence to support this. But you never know...

RE: perceiving your rotation as hard/old school, I rotated with a gen surg attending who was an alumnus of my medical school. He stayed on to do residency and fellowship at our institution, and was then hired as faculty. He's an interesting case, because he's seen the medical student experience at my school in particular change over the last 15 years from pretty much all perspectives (student, resident, fellow, attending). He's well-known as an attending that lets students and residents do a ton in the OR. At the end of my clerkship, he told me that he just feels bad for students from our generation. When he was in my shoes at my school 15 years ago, he was putting in central lines, writing orders, closing fascia, intubating, etc... He never had to attend (often useless) didactics to study for a shelf that is disproportionately responsible for our rotation grade, etc... So I'm pretty sure my surgery rotation isn't hardcore or old school, but I think it has retained some of the important positives and negatives from the "old school" days. That said, I have no doubt that it's overall a lower quality clerkship compared to 15 yrs ago and only heading in the wrong direction.

 

[vhawk]

I think you have a point, but in my experience the "horrible, entitled, lazy students" that OP describes are pretty easy to spot. I don't think we have many of them in our surgery clerkships, because they not infrequently asked to repeat the clerkship. I hope I'm not one of them, and I think I could give evidence to support this. But you never know...

RE: perceiving your rotation as hard/old school, I rotated with a gen surg attending who was an alumnus of my medical school. He stayed on to do residency and fellowship at our institution, and was then hired as faculty. He's an interesting case, because he's seen the medical student experience at my school in particular change over the last 15 years from pretty much all perspectives (student, resident, fellow, attending). He's well-known as an attending that lets students and residents do a ton in the OR. At the end of my clerkship, he told me that he just feels bad for students from our generation. When he was in my shoes at my school 15 years ago, he was putting in central lines, writing orders, closing fascia, intubating, etc... He never had to attend (often useless) didactics to study for a shelf that is disproportionately responsible for our rotation grade, etc... So I'm pretty sure my surgery rotation isn't hardcore or old school, but I think it has retained some of the important positives and negatives from the "old school" days. That said, I have no doubt that it's overall a lower quality clerkship compared to 15 yrs ago and only heading in the wrong direction.

True but bear in mind that is not the only thing for him that has changed over those 15 years.

 

[SLUser11]

Besides hurting feelings, why not bring these to the forefront?

I think the fact that you are a non-trad has a larger impact on your preferred model for learning than you think. Millennials must be approached with kid gloves. Too much negativity, and they will begin to question their snowflake status, and you basically lose your learner.

Honestly, I think we'll be having this conversation (or one similar) 15 years from now, with the 2015 students, now seasoned attendings, complaining about "students these days," so take everything we complain about here with a grain of salt.

Here's an interesting "similar thread" that popped up at the bottom of this one, talking about the problem with surgical education back in 2010:
http://forums.studentdoctor.net/threads/the-problem-with-surgical-education-today.724946/

It has a horrible Kansas pun from myself, some false senses of adequacy from SteadyEddy, and plenty of other entertaining tidbits.

 

[VisionaryTics]

Here's an interesting "similar thread" that popped up at the bottom of this one, talking about the problem with surgical education back in 2010:
http://forums.studentdoctor.net/threads/the-problem-with-surgical-education-today.724946/

It has a horrible Kansas pun from myself, some false senses of adequacy from SteadyEddy, and plenty of other entertaining tidbits.

Ever notice how sucky attendings are at assisting on cases? They retract worse than the medical students sometimes. And don't misunderstand. If we're short-handed on a lap chole, for example, the attending can drive the camera while operating just fine. But for some reason if I'm operating and the attending is driving the camera they absolutely blow. It's to the point where I think they do it on purpose because it's so poor. Like, I won't have any view of anything and they'll be yelling about how I'm "doing it wrong." Then they'll give me the camera, I'll move it to the right position where suddenly you can see everything, the attending does the case is a few minutes, and everyone rolls their eyes over how you "couldn't do a simple lap chole." Once I deliberately kept the view where the attending had it when he gave me the camera and he immediately started yelling "GET ME THE VIEW! CENTER!! CENTER!!!"

Glad this isn't just me. I was dissecting the GB off the liver bed the other day while simultaneously:

1. Standing with my back to the monitor, looking over my shoulder (my attending likes people on the same side to stand belly-to-belly rather than side to side)
2. With my view obscured by a poorly-placed IV pole with 3 bags of irrigation hanging on it
3. The scrub tech repeatedly dropping the fundus of the GB while retracting
4. The camera focusing somewhere around the area of the Pouch of Douglas, from a distance of two or three miles

I then proceeded to pop the GB and cover my nice plane in bile. Too much fun. In my head I was begging the attending to give the camera to a random med student pacing the corridor.

At least he let me struggle.

 

[dienekes88]

I think the fact that you are a non-trad has a larger impact on your preferred model for learning than you think. Millennials must be approached with kid gloves. Too much negativity, and they will begin to question their snowflake status, and you basically lose your learner.

Honestly, I think we'll be having this conversation (or one similar) 15 years from now, with the 2015 students, now seasoned attendings, complaining about "students these days," so take everything we complain about here with a grain of salt.

Here's an interesting "similar thread" that popped up at the bottom of this one, talking about the problem with surgical education back in 2010:
http://forums.studentdoctor.net/threads/the-problem-with-surgical-education-today.724946/

It has a horrible Kansas pun from myself, some false senses of adequacy from SteadyEddy, and plenty of other entertaining tidbits.

Did they grow up that way? Or did we make them that way.

There is the aspect of being children of the "Me" Generation, i.e. Parents born between 1946 and 1964, that makes this generation particularly interesting. However, I think the first two years are spent cultivating it. Too much focus on individuality and creativity, and quite honestly not enough time spent on what I still believe is the meat of medical and surgical training: sitting down and memorizing the physiology, the pathophysiology, the diagnostic criteria, the guidelines, the indications for an operation, the steps to the operation, etc. Most of progress is incremental, and it requires a good understanding of what is out there already.

Having said all that, I totally play into it. I don't want to hear from the clerkship director or my program director about being too tough on the students, so I largely let them do whatever they want. I've seen a few senior residents dressed down for breaking the rules in small ways to try to further the students' education (coming in earlier, following more patients, etc.). I don't need that.

 

[Handinhand]

As an M3 going through surgery currently I feel fairly qualified to respond.

If you want your students to be more engaged, and less focused on the shelf and book knowledge, then how about you not make that stupid little shelf exam worth 40% of my surgery clerkship grade? Until that happens, you better believe I'm going to want to bounce out of the hospital ASAP every night and weekend to get to the library and study. It's ironic because the kids who worry the most about this are the ones who want to go into surgery and are worried more than all the other students about the grade they get on the rotation.

I certainly didn't come to medical school wanting to sit inside a concrete prison every weekend of my life studying, but that's what medical education has become. It doesn't stop after the first two years or step 1. We have lectures every week that pull us off service for most of the day, OSCE's to prepare for, busy work to complete in the form of H&Ps and online learning modules, etc. There is so much other stuff beyond showing up on service every day that it makes it impossible to connect with the rotation and really take anything meaningful away from it.

 

[Winged Scapula]

As an M3 going through surgery currently I feel fairly qualified to respond.

If you want your students to be more engaged, and less focused on the shelf and book knowledge, then how about you not make that stupid little shelf exam worth 40% of my surgery clerkship grade? Until that happens, you better believe I'm going to want to bounce out of the hospital ASAP every night and weekend to get to the library and study. It's ironic because the kids who worry the most about this are the ones who want to go into surgery and are worried more than all the other students about the grade they get on the rotation.

I certainly didn't come to medical school wanting to sit inside a concrete prison every weekend of my life studying, but that's what medical education has become. It doesn't stop after the first two years or step 1. We have lectures every week that pull us off service for most of the day, OSCE's to prepare for, busy work to complete in the form of H&Ps and online learning modules, etc. There is so much other stuff beyond showing up on service every day that it makes it impossible to connect with the rotation and really take anything meaningful away from it.

At least here, the decision about what percentage of your grade is from the shelf (and all that extra stuff) is from medical school administration; I had no decision making in that process. Talk to your medical school rather than blaming the surgeons for noticing that students are less engaged than they used to be. Believe me, we're frustrated too - half the time the students aren't even around due to mandatory outside "stuff" their school makes them do.

 

[Pir8DeacDoc]

As an M3 going through surgery currently I feel fairly qualified to respond.

If you want your students to be more engaged, and less focused on the shelf and book knowledge, then how about you not make that stupid little shelf exam worth 40% of my surgery clerkship grade? Until that happens, you better believe I'm going to want to bounce out of the hospital ASAP every night and weekend to get to the library and study. It's ironic because the kids who worry the most about this are the ones who want to go into surgery and are worried more than all the other students about the grade they get on the rotation.

I certainly didn't come to medical school wanting to sit inside a concrete prison every weekend of my life studying, but that's what medical education has become. It doesn't stop after the first two years or step 1. We have lectures every week that pull us off service for most of the day, OSCE's to prepare for, busy work to complete in the form of H&Ps and online learning modules, etc. There is so much other stuff beyond showing up on service every day that it makes it impossible to connect with the rotation and really take anything meaningful away from it.

Well let'e be honest. The need to read and study at night and on the weekends never goes away. It gets MUCH worse during residency. My residency was cushy compared to the GS guys here but I still worked 65 + hours and then would come home to read for the next days cases, prepare a lecture/presentation, logging cases, reading for in service etc. I'd guess I spent another 20 + hours a week doing other things. I'm not complaining as I Loved my residency. But let's not act like medical students are the only ones that have other things to consider.

 

[dienekes88]

When I sit down with students and talk with them, or ask them questions in a different context, I would really disagree with the bolded part. They know A TON. They have the basic science stuff down cold. Their physiology and pathophysiology knowledge is impressive.

Where they struggle is the practical application of that knowledge in a clinical setting. Which is, I think, where we fit in in their education. Helping them take what they've learned and fit it into a clinical context.

Agree mostly. The context within which they have information is usually a controlled setting typically with a well-defined, well-worded prompt and multiple choice answer. If they truly had it down cold, then it wouldn't be difficult to make it to the practical application. If you ask them the DO2 equation, most don't know it off the top of their heads... or even the components of it. Same goes for understanding the relationship between blood pressure, cardiac output, and peripheral resistance. These are basic concepts.

We're here to shepherd them through the transition from classroom to the ward, but a lot of what I find myself doing is reviewing classroom stuff, going over indications, reviewing guidelines... pretty dry stuff.

 

[SplenoMegastar]

Of course residents have plenty of reading to do and the expectations of them are a lot higher than the pretty low expectations anyone has of med students. I think part of the reason students feel so inadequate in surgery is that a lot of what we have to learn to think about doesn't come up in M1/M2 the way IM and neuro stuff comes up. So I felt like I was really starting with a poor fund of knowledge that was applicable to surgery, and I'd imagine that some students felt similarly.

I know there are a lot of surgery bashers that like posting about how awful their experiences were. But I'd propose that just like SDN is full of people posting their 250++ step scores which is clearly not average, maybe there is a surgery med student version of overachieving that actually took the rotation more seriously, lurk here all the time hanging on your every words (because there is clearly a different set of boundaries with our attendings in regular life), and are still just excited about our surgery rotations even though we clearly weren't functioning like interns.

 

[Pir8DeacDoc]

Of course residents have plenty of reading to do and the expectations of them are a lot higher than the pretty low expectations anyone has of med students..

I think you've missed my point. The medical student excuse of "I've got to study for the shelf" really doesn't fly with me. I want you to do well on your test, but squeezing out time to get things done efficiently is a function of being a surgeon and physician. Unless clerkships have changed in the few years since I was in residency, there is still plenty of time to read and study if you prioritize your time properly. Surgery makes students uncomfortable because it's learning by seeing and watching, not by sticking a nose in a book. Yes, a certain amount of book knowledge is necessary. However, you'll remember WAY more from seeing cases and patients, even if just shadowing, then you ever would from a book.

 

[SplenoMegastar]

I think you've missed my point. The medical student excuse of "I've got to study for the shelf" really doesn't fly with me. I want you to do well on your test, but squeezing out time to get things done efficiently is a function of being a surgeon and physician. Unless clerkships have changed in the few years since I was in residency, there is still plenty of time to read and study if you prioritize your time properly. Surgery makes students uncomfortable because it's learning by seeing and watching, not by sticking a nose in a book. Yes, a certain amount of book knowledge is necessary. However, you'll remember WAY more from seeing cases and patients, even if just shadowing, then you ever would from a book.

I don't disagree with any of your points, I was just making a different one.

 

[KinasePro]

I think the fact that you are a non-trad has a larger impact on your preferred model for learning than you think. Millennials must be approached with kid gloves. Too much negativity, and they will begin to question their snowflake status, and you basically lose your learner.

Honestly, I think we'll be having this conversation (or one similar) 15 years from now, with the 2015 students, now seasoned attendings, complaining about "students these days," so take everything we complain about here with a grain of salt.

Meh, I think painting with broad strokes as you do in bold causes its own set of troubles. I can't speak for your experience with millenials, and perhaps you were burned by some sensitive students in the past. But when I look at my class, I see generally pretty mature people who fit the millenial definition but defy the stereotypes. Most of them have dealt with a fair share of criticism prior to medical school (majority are non trad these days). I don't think my school is especially unique in admitting these types of "millenials," which is reflected in the increased average age and experience of matriculants as admissions become more competitive with each year. I know for myself, I probably wouldn't be given an interview at my own medical school if I were applying in 2015 with my undergraduate credentials.

If a millenial stereotype can be attributed to medical students in 2015, I think it is their general disillusionment with authority. I notice my classmates are pretty critical of authority figures, quick to point out hypocrisy, and doubtful that our superiors take our opinions/feedback seriously. IMHO medical students are fairly cynical (just take a look at allo these days...), and realize that despite all the hoo rah-ing from @Pir8DeacDoc and his colleagues about balancing book study and clinical duties, the difference between an "H" and "HP" is ultimately your percentile score on the national shelf exam. And the difference between getting AOA or not is whether you got an "H" or an "HP" in surgery. And the difference between getting >20 interview offers out of 90 applications and <10 interview offers in orthopaedic surgery this year is whether you got AOA or not (wish I were joking...). So these are the reasons that otherwise excellent students would rather be studying in the library than retracting during your whipple --- because it is more likely to carry them to the next step in becoming the doctor they want to be. I agree this mindset is very flawed, but it's definitely incentivized by the current medical education system.

 

[Pir8DeacDoc]

Sorry you interpreted my statements as Hoo rah-ing. It's my honest assessment that I want you to do well on your shelf but in the big boy world you have to balance things out. You're not helping your case much IMHO.

Your situation sounds really stressful. I'm glad I didn't have to worry about that sort of stuff when I was in med school. ENT was super easy when I was coming along

 

[KinasePro]

Sorry you interpreted my statements as Hoo rah-ing. It's my honest assessment that I want you to do well on your shelf but in the big boy world you have to balance things out. You're not helping your case much IMHO.

Your situation sounds really stressful. I'm glad I didn't have to worry about that sort of stuff when I was in med school. ENT was super easy when I was coming along

I think your sarcasm shows that my interpretation was correct. It sounds like you're saying, the "big boy world" is going to be too difficult for young whippsersnappers from my generation to balance, etc... While I'm arguing that in the "big boy world" the incentives are more aligned with doing an excellent job in your current role. Whereas for medical students, the incentive is to simply match as well as you can. Those situations are very, very different IMO.

Don't get me wrong though, I'm not trying to complain. I like to think that I managed to balance things pretty well coming though. My attendings were either pleased or great actors. I'm just trying to bridge the generational gap here... med students have always had competing personal interests, but today I believe our actual participation in real patient care is at an all time low. We "play doctor" more than ever before, and naturally this breeds some apathy and causes students to focus on what is most likely have an effect on their careers-- shelf exams, board exams, and the like.

 

[Pir8DeacDoc]

Despite your implications to the contrary, I'm not trying to play the "old school tough guy" routine. My sarcasm shows the same point I made earlier in the thread. Med students don't like surgery because you are required to learn by reading and shadowing /watching/doing. It's also a hard transition to clerkships in general. You go from learning and reading from books to finally actually doing doctor type things. My overall point is that complaining about shelf exams and grades makes you and other med students sound like whiners. We were all there once. We get it that time is limited. But going forward that skill set and need to balance your time and energy won't get any easier. Cheers

 

[maxxor]

I think your sarcasm shows that my interpretation was correct. It sounds like you're saying, the "big boy world" is going to be too difficult for young whippsersnappers from my generation to balance, etc... While I'm arguing that in the "big boy world" the incentives are more aligned with doing an excellent job in your current role. Whereas for medical students, the incentive is to simply match as well as you can. Those situations are very, very different IMO.

Don't get me wrong though, I'm not trying to complain. I like to think that I managed to balance things pretty well coming though. My attendings were either pleased or great actors. I'm just trying to bridge the generational gap here... med students have always had competing personal interests, but today I believe our actual participation in real patient care is at an all time low. We "play doctor" more than ever before, and naturally this breeds some apathy and causes students to focus on what is most likely have an effect on their careers-- shelf exams, board exams, and the like.

@KinasePro
You gotta remember, things have changed a LOT in the past decade, to where even newly minted attendings in long-training specialties no longer have a relevant perspective with the new application process.

During my time as a medical student, USMLE average scores rose from 220 on my score report in 2012 to 230 in 2014. That's a 10 point jump in 2 years. The competition to get AOA/Honors/Killer shelf scores is heating up and squeezing out actual hands-on clinical training. My medical school uses shelf exams as a negative filter; if you aren't above some arbitrary percentile, you aren't eligible for Honors, clinical performance be damned. Oh, and that percentile? It's not national percentile, it's compared to students from the previous year's test administration. For example, I had to get above 80th percentile of all the previous year's medical students to "qualify" for Honors in internal medicine. Even if I had been a superstar MS3 acting beyond the level of an intern with stellar evaluations, without that 80th percentile, I would be given a "satisfactory". End of story.

 

[KinasePro]

My overall point is that complaining about shelf exams and grades makes you and other med students sound like whiners. We were all there once. We get it that time is limited. But going forward that skill set and need to balance your time and energy won't get any easier. Cheers

But what do you expect in a thread that laments how med students these days need to be treated with "kid gloves" if they want to be ready for the "big boy world" (everyone else's words, not mine). When current student defend themselves, it's "whining".

That's like me asking you "when did you stop beating your wife?" and then faulting you for being defensive in your answer.

 

[Pir8DeacDoc]

Surely you can come up with a more appropriate way to make your point.
My response to some such asinine assertion like that would be a smile and a nod. If something doesn't apply to you, then you give it little thought or credence. By becoming overly defensive and telling everyone how hard it is to get honors and shelf exams suck, etc it comes across like a whiner. I've been to med school. I know what it's like. Do you honestly think somehow things have gotten harder? Don't kid yourself.

 

[KinasePro]

Surely you can come up with a more appropriate way to make your point.
My response to some such asinine assertion like that would be a smile and a nod. If something doesn't apply to you, then you give it little thought or credence. By becoming overly defensive and telling everyone how hard it is to get honors and shelf exams suck, etc it comes across like a whiner. I've been to med school. I know what it's like. Do you honestly think somehow things have gotten harder? Don't kid yourself.

The wife beating question is just a classic example of the fallacy I'm pointing out in this thread. If you smiled and nodded, everyone would think you were a wife beater. The natural response is to clear yourself of the charges which is why it's famous and so frequently cited. Sorry, but I don't buy that you would smile and nod like a robot, instead you would clear the air like any loving husband would. "Do med students suck because they're millenials or because we're being too easy on them?" The discussion in this thread has become a loaded question to medical students browsing SDN. Defend yourself = whiner. Say nothing = tired stereotypes go unchallenged.

Of course things have gotten harder. But I don't really need to argue this, charting outcomes and the rest speak for themselves.

 

[Pir8DeacDoc]

OK...you got me. Well done! You've got all the answers. No reason for anyone to carry on a dialogue with all knowing med student.

Good news for me is I'm where I want to be.. How bout you?

 

[Mr Cookie Pants]

Med school is worthless because medicolegally students really can't do anything any more. Im a 3 and was a Med 3 in 2010. I had a function of getting the vitals, labs and prewriting the notes, then writing the acutal note on rounds. The list was a carefully guarded word document that needed updating 2-3 times a day...all stuff for the med student. Now med students can't write notes, vitals are pre-populated, as is most of the list. There's been a pretty big shift in the past 5 years.

Med students are about the 'educational experience now', not job training as previous have thought. When I was a MS3, my PGY 5 said she carried the intern pager and was an 'acting intern' as in the nurses called her, she gave an order and the intern cosigned it in a reasonable amount of time. That definitely didnt exist by the time I was a MS3, but as I mentioned I felt like a team member. as a result, I put in a few lines, a chest tube and did some suturing. I maybe went to 1-2 1hr didactic sessions a week. I took real call. Now med students have something almost daily, they dont take call. And as a result, they're worse interns, which means that the med students get to do less, because the interns are showing up worse, etc. It's a cycle that's becoming more apparent each year!

 

[SLUser11]

Meh, I think painting with broad strokes as you do in bold causes its own set of troubles. I can't speak for your experience with millenials, and perhaps you were burned by some sensitive students in the past. But when I look at my class, I see generally pretty mature people who fit the millenial definition but defy the stereotypes. Most of them have dealt with a fair share of criticism prior to medical school (majority are non trad these days). I don't think my school is especially unique in admitting these types of "millenials," which is reflected in the increased average age and experience of matriculants as admissions become more competitive with each year. I know for myself, I probably wouldn't be given an interview at my own medical school if I were applying in 2015 with my undergraduate credentials.

If a millenial stereotype can be attributed to medical students in 2015, I think it is their general disillusionment with authority. I notice my classmates are pretty critical of authority figures, quick to point out hypocrisy, and doubtful that our superiors take our opinions/feedback seriously. IMHO medical students are fairly cynical (just take a look at allo these days...), and realize that despite all the hoo rah-ing from @Pir8DeacDoc and his colleagues about balancing book study and clinical duties, the difference between an "H" and "HP" is ultimately your percentile score on the national shelf exam. And the difference between getting AOA or not is whether you got an "H" or an "HP" in surgery. And the difference between getting >20 interview offers out of 90 applications and <10 interview offers in orthopaedic surgery this year is whether you got AOA or not (wish I were joking...). So these are the reasons that otherwise excellent students would rather be studying in the library than retracting during your whipple --- because it is more likely to carry them to the next step in becoming the doctor they want to be. I agree this mindset is very flawed, but it's definitely incentivized by the current medical education system.

You ask that I do not paint millennials in a broad stroke, but that's sort of my whole point. The stereotype of current learners is that they demand that I appreciate just how unique they are, and how uniquely talented they are, so obviously if you ask a bunch of snowflakes how they feel about themselves, they will confidently say that they are nothing like the unfair labels that have been forced upon them.

I agree with your comments that snowflakes are very critical of authority. This is sometimes healthy, but is often taken too far. The disrespect for authority, and general disregard for hierarchy, is often interpreted by older generations in an extremely negative fashion...but can you blame them?

You admit that students are cynical, and critical of authority figures, which is often interpreted to mean they feel entitled and think they're smarter than their teachers, but then they are surprised/upset when these teachers don't feel too motivated to provide educational substrate to a non-captive, generally disrespective and disinterested audience......

I think the big fallacy that must be addressed upfront is that somehow the process is much harder now for snowflakes than it was for students in the past. It's always been hard. Conversations 10 years ago were extremely similar to those had today....just do some thread searches on SDN if you need some proof.

Still, I think it's equally important that current teachers admit that things aren't any easier, either, as the uphill-in-the-snow-both-ways approach to education is not too effective.

 

[vhawk]

OK...you got me. Well done! You've got all the answers. No reason for anyone to carry on a dialogue with all knowing med student.

Good news for me is I'm where I want to be.. How bout you?

You are embarrassing yourself, maybe take a step back. I'm much closer to your end of the spectrum on this topic than to the other guys, but this is just a really gross post, especially with the high ground you are attempting to take.

 

[vhawk]

You ask that I do not paint millennials in a broad stroke, but that's sort of my whole point. The stereotype of current learners is that they demand that I appreciate just how unique they are, and how uniquely talented they are, so obviously if you ask a bunch of snowflakes how they feel about themselves, they will confidently say that they are nothing like the unfair labels that have been forced upon them.

I agree with your comments that snowflakes are very critical of authority. This is sometimes healthy, but is often taken too far. The disrespect for authority, and general disregard for hierarchy, is often interpreted by older generations in an extremely negative fashion...but can you blame them?

Yes? Hierarchy for the sake of hierarchy is bad and stupid and counterproductive. There is a ton of that in medicine. Now, there are also very good reasons for it sometimes, and for example in the OR or in many situations, its like the military, you need to respect the hierarchy because thats how things get done safely, and we dont always have time to debate things in an open forum.

But yes, I can blame older attendings or residents for getting butthurt every time the sacred hierarchy gets questioned.

You admit that students are cynical, and critical of authority figures, which is often interpreted to mean they feel entitled and think they're smarter than their teachers, but then they are surprised/upset when these teachers don't feel too motivated to provide educational substrate to a non-captive, generally disrespective and disinterested audience......

I think the big fallacy that must be addressed upfront is that somehow the process is much harder now for snowflakes than it was for students in the past. It's always been hard. Conversations 10 years ago were extremely similar to those had today....just do some thread searches on SDN if you need some proof.

Still, I think it's equally important that current teachers admit that things aren't any easier, either, as the uphill-in-the-snow-both-ways approach to education is not too effective.

Agree, its just the same **** over and over again, and in 10 years this same discussion will be being had between the last remaining human residents and their cyborg med students

 

[dyeguy21]

As a recent finisher of a surgery rotation I can tell you a lot of it is Attendings/Residents not telling us at all what they want us to do. I really wanted to do ortho for the longest time, but the lack of teaching made me really not wanna go into it.

Examples: I was on a hand surgery rotation. One of the doctors, despite presenting to him and draping patients the exact way he wanted them, never acknowledged my existence. He would literally never make eye contact with me during presentations and would cut me off and ask the resident, who hadn't seen the patient, a question about the patient I was in the middle of presenting. This happened about 15 times, then I gave up. It seemed unprofessional and disrespectful, but I was a 3rd year student I have no power and the surgeon gets to grade me and can affect my career forever.

I was also on a gen surg rotation and the clinic day was going to ****. A random fellow was in office and was terrible at keeping office pace. We had 10 rooms loaded, 2 had been seen, and we were an hour and a half behind. I took over, started seeing patients, wrote the beginning of office notes, and started directing traffic for the fellow and the attending on which patients to see next to reestablish flow. We finished only a half hour behind. Not a single thank you or good work. And I learned almost nothing that day.

I did 2 weeks of urology and got to hold a wire once. The rest of the time I watched cystoscopes, flouroscopes, and robot surgery monitors, usually while wearing lead with little to no teaching occurring to point out stuff.

I still had to see patients in the morning, change dressings (including wet to dry and debridement), place foleys, do rectals, remove sutures, change ostomy bags, do post op checks, make splints, and suture lacs. Again no "strong work" from resident or attending, or any advice on how to improve certain skills. All of these rotations were super gung ho about getting you in to see surgeries and do stuff. The problem is when you get to do stuff it means hold suction/traction at arms length and not be able to see anything while the intern begs to use the bovie. The sheer apathy of anyone to teach us anything made me love regular medicine instead, because it seemed like I would at least be able to learn something. The worst is that I would ask for feedback and the resident/attending would always say you are doing great! Ok, anything more I can do to help? You're doing much more than we expect of you! and then grades come back and you're bewildered as to why you haven't earned honors. If I need to improve....let me know, you're not gonna hurt my feelings. You'll make me want to do better. If I'm exceeding your expectations, however, please say so by rewarding my efforts. I didn't wanna do 200 rectals and place 144 foleys (this is not an exaggeration), but I did them because I'm a med student and I know I need practical skills.

 

[VisionaryTics]

Not a single thank you or good work. And I learned almost nothing that day.

****, man, if I relied on "attaboys" to get through the day, I would've shot myself July 10th.

The more concerning thing is the second sentence.

1. You did learn something because you learned how to work within the clinic system and get things going (an INCREDIBLY valuable skill, underlined by the fellow's lack of it apparently),
2. Clinic is tough to teach in. When I have med students in clinic with me and we're behind, I unfortunately don't have time to go over CT scans or finer points of the exam or whatever and the attending who is bouncing from room to room certainly doesn't. Listen to what your residents and attendings are saying to patients, watch how they do their exams and ask to check abnormal findings if you hadn't done so previously, etc. That's how you learn in a surgical clinic. No one is going to sit down with the med student for 15 minutes going over a topic.

I still had to see patients in the morning, change dressings (including wet to dry and debridement), place foleys, do rectals, remove sutures, change ostomy bags, do post op checks, make splints, and suture lacs. Again no "strong work" from resident or attending, or any advice on how to improve certain skills. All of these rotations were super gung ho about getting you in to see surgeries and do stuff. The problem is when you get to do stuff it means hold suction/traction at arms length and not be able to see anything while the intern begs to use the bovie.

Those are all incredibly useful skills that many, many med students and interns do not have any sort of faculty with. Wrt to the OR, that's the job as a med student. Maybe you'll get to suture a bit. What else would you like to do? I lucked out with the occasional first assist or small case, but there were weeks to months between those experiences sometimes. You'll get to operate in residency, if you want to go into surgery.

 

[Arcan57]

From the perspective of someone that did an "old-school" M3 rotation after the shelf-exam was the predominant part of the grade but before the era of "med students are useless because of EMR", the main problem I had with the rotation was that I finished without any idea of whether I'd be a good surgeon. I loved the work-up of surgical problems and could deal with the hours and enormous patient care load. In the OR, I retracted for hours typically in a position that didn't allow me to see any of the relevant anatomy and no one spoke to me unless they had their hands full and couldn't just grab my hand to reposition the retractor. My knot tying was abysmal the first day I was in the OR and despite spending hours working on improving I didn't get another chance to actually tie during those 8 weeks. I didn't hold a scalpel except to pass it and the only time I used a bovie was to touch it to a clamp placed by the attending. I left the rotation with an A because I did well on the shelf and could repeat back a reasonable work-up for the most common surgical diseases (which I hadn't actually seen managed due to being randomized into rotating through HPB and vascular for my 2months). I had no knowledge of surgical anatomy, but since nobody ever asked me about it that didn't matter. It was a far better strategy to read on the stuff that was going to be on the shelf and oral versus trying to understand the nuts and bolts of an operation that only a handful of surgeons in the country would even attempt.

To lend support to a previous posters thoughts, I actually learned the most from a complete bastard of a chief (bragged first day about having made Marines that had rotated with him cry) during the week I was on trauma. He was abrasive but he actually cared if we learned something and used the post-case/pre-nighttime period to actually sit down and teach us by finding where our fund of knowledge ended and filling in the next steps.

 

[dyeguy21]

It does sound like they had a pretty crummy surgery rotation if they were getting ignored, cut off mid presentation, etc.

That said - you're absolutely right...if you're someone who needs attaboys and pats on the head, surgery is not the right field for you.

I'm aware there was no time to sit down and have a chat, but I was so busy getting new patients ready that I was just using my previous outpatient rotation skills to get the office moving that I also didn't get to go in with the attending or the fellow until the last patient of the day. I also know that all the skills I picked up are important and that's why I wanted to experience them and get practice under my belt

I also don't think I need attaboys, I need recognition of a job well done, however small, especially come grading time. It's like getting punched in the gut if you work your absolute ass off, come in earlier than other med students, leave later, ask for feedback (and get told you're performing far above expectations), answer pimp questions correctly, do "scutwork" enthusiastically, actually stay for call days and still get a 3/5 or 4/5 because I don't know what more I could do to achieve the grade I was aiming for. I will never stay up late thinking about my average grades on that rotation, but that's one of the many reasons I decided to not bother with surgery; the absolute lack of recognition, from acknowledging that I even exist all the way to not admitting that I did everything they asked and then some. Every other rotation challenged me to be better and rewarded me for my progress. Surgery seemed like everyone was so caught up in their own struggle to become better that they couldn't take the time to notice the achievements of others.

I think my point still stands that other rotations and disciplines gave me clear guidelines and expectations and inspired me to be better. Surgery was more of a sandbox and you had no way of knowing what was required of you to be seen as competent in the field. Perhaps that is surgery in and of itself, but for MS3's it means I can do a little or a lot and still come out the other side being seen as equal to my peers regardless of effort.

 

[Handinhand]

I think the big fallacy that must be addressed upfront is that somehow the process is much harder now for snowflakes than it was for students in the past. It's always been hard. Conversations 10 years ago were extremely similar to those had today....just do some thread searches on SDN if you need some proof.

That's just flat out incorrect. Take one look at the rise in average Step 1 scores and shelf exams over the last few decades. The average for Ortho was 245 last year, 248 for ENT, probably just as high for Uro. Since you've been through this process I'm sure you understand that's a very difficult score to get, and that's just the average! There is immense pressure now in medical school to do well on all of the standardized testing. At the same time, very little of what happens on rotation, ESPECIALLY on surgery, is relevant to these exams. I would say 99% of what I get pimped on during a case is anatomy, of which, exactly 0% is useful knowledge for a shelf exam. At the same time, clinic evals are still a giant portion of your overall grade. So what happens is that your attending thinks you need to stay until 8PM to watch a TV screen of your 20th lap appy of the rotation because that's what he did when he was a student, and you stay and feign enthusiasm because you want to get good evals. At the same time, staying until 8PM means I'm going to get no studying done for the shelf. If you're eager to get out to go study though, as clearly supported by the attendings in this thread, then you're being a whiny, lazy medical student. You just can't win.

I'm not saying this isn't a continuing argument made by students, but I believe that it's always becoming more difficult every year to progress through this field. I'm certainly not too proud to admit that the kids coming after me are going to have it even harder. Christ, I look at how competitive it's gotten to just be accepted to medical school now even over the 3.5 years I've been in school, and I'm glad I got in while I did. When I started undergrad, if you got a 30 on your MCAT, you were golden. By the time I was applying, if you got a 30 you should be thinking about retaking. Now? My MCAT score, which would have been incredible when I started undergrad, is just average.