Medical students today are getting richer clinical training

I recently served as a preceptor for first year students at our Hofstra-North Shore LIJ School of Medicine who were doing one of their RIA (reflection, integration and assessment) sessions. The students do these sessions every 12 weeks, and are generally scheduled with the same preceptor over time. It may be routine for the students, but I found it absolutely remarkable.

Each student is responsible for doing a complete history and physical examination on a standardized patient as the preceptor watches through one-way glass and listens in with headphones. After 40 minutes, the students exit the room and have 10 minutes to organize their thoughts and enter their write-ups into a computer-based tool. The student then presents the case to the preceptor, and feedback is provided to the student by the patient and the preceptor. Preceptors and patients also use computer-based tools to document the student’s performance at interviewing and examining.

The whole thing blew me away.

First, the venue. The RIAs are done at our system Center for Learning and Innovation (CLI) a state of the art educational center, which includes classrooms, simulation facilities, and over a dozen exam rooms equipped to allow the observation and recording of students interacting with standardized patients. The patients are professional actors who are extensively briefed on the details of the case and trained to observe and evaluate the students’ performance. They were great: absolutely credible, and insightful in their comments to the students about how the encounter felt from the patient’s perspective. There was also clearly a lot of prep work that had been done behind the scenes to develop the case, including creating an elaborate back story for the patient so that virtually any question the student might have asked — any pets at home? — would have been answered in a standard fashion.

Even with all that, the students were the real stars of the day. Sure, most of the students got caught for time and were unable to take a complete history and do a complete physical exam in the time allotted. Some got sidetracked, spending time on, for example, probing the choice of contraceptives of a post-menopausal woman, or failing to pursue a really important detail of the presenting complain.

And yes, their physical exams were a bit awkward: One student used her own right eye to examine the patient’s left eye, another listed to the heart from the left side of the exam table, and one seemed to be listening for the Korotkoff sounds over the ulnar nerve.

But here’s the thing. These were first-year students, and they were doing a complete history and physical. How many of us even knew which end of the stethoscope to stick in our ears when we were first year students? It struck me that being critical of their performance is a little like complaining about the musicality of a singing dog — it is a miracle that the dog can sing at all!

I think it is fabulous that our students are getting much richer clinical training and more effective feedback than I ever got, and it made me proud to be a part of it.

Ira Nash is a cardiologist who blogs at Auscultation.

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  • EmilyAnon

    Why does a standardized patient deserve to be paid, but the sick patient, who offers real learning value to these students, doesn’t even get a discount.

    • RuralEMdoc

      A medical student can be a valuable asset to a sick patient. They are the ones have an abundance of time to spend with their patients (they frequently have only one or two assigned to them), and they are not allowed to write orders.

      It is one more pair of eyes on the patient, and that is important, no matter how inexperienced they are.

      • EmilyAnon

        I am thinking more when the inexperienced student has access to a patient’s body performing first time, usually awkward, physical exams, which can be very embarrassing. (wasn’t it for this very reason that professional patients were utilized?) I still want to know why the patient isn’t given a break on their bill when in this type of encounter with new students, the benefit gained only goes one way. If such a gesture is offered, I think some patients’ resistance to being practiced on might soften.

        • RuralEMdoc

          Sure give them a “discount” if they see the student……Of course that would make it even less likely that medical students get to actually see patients because the hospital will restrict their access if it hurts their bottom line, which would further exacerbate the aforementioned problem of replacing actual patients with fake ones.

          Regarding the first time physical exam. Yes, they can be comically awkward ( I know mine was), but everything has to be done for the first time.

          Standardized patients are weird. Most of them are horrible actors, and it’s not real. It feels more like trying out for a role on Grey’s Anatomy then actually being a doctor. Also the previous model where we did physical exams on each other during our early med school years is more than sufficient to work out the awkward kinks. You don’t get good at the physical exam until you have done thousands and seen thousands of abnormal exams. Standardized patients are a crap learning tool because they all have normal findings. The best you can hope for is that one of the “actors” has a benign heart murmor or something.

          In conclusion, I believe medical school clinical years have been watered down, med students are no longer allowed any patient responsibilities, schools are graduating unprepared residents, and they are replacing valuable patient encounters with silly fake ones.
          In case you hadn’t heard, there are lots and lots of real patients to be seen, we do not need to use fake ones.

        • guest

          Patients who feel uncomfortable about having medical students involved in their care are more than welcome to choose non teaching hospitals for their treatment.

  • RuralEMdoc

    I was thinking the same thing as I read this article.

    I am NOT impressed by the standardized patient experience.

    Tuition costs are skyrocketing to pay for this crap, meanwhile in the hospitals medical students are completely removed from any meaningful patient interactions for a whole gamut of reasons.

    In my teaching hospital most medical students could be found sleeping in the library during the day, because there is no role for them on medical teams anymore, and that is the real state of medical education.

  • doc99

    How many deliveries do these fortunate students of today perform on their OB rotations?

  • pmanner

    Actually, this reminds me of the music field. It used to be that a budding singer or musician spent years doing the grunt work of really learning their instrument – scales, singing on pitch, etudes. Now they yap something into a computer, turn on Auto-Tune, or “sample” previously recorded tracks, and spit out product.

    Sorry. It may look like a clinician, it may walk like a clinician, but it ain’t one. How can you be a surgeon if you’re ignorant of anatomy? Or physiology? How can you be a neurologist if you have no idea what the pathways in the spinal cord are?

    I agree that the old pump-and-dump of grinding out two years in the library, then forgetting 99% of it, wasn’t good either. But this? Not sold on it.

    • Patient Kit

      I think your analogy of music to medicine is a good one. If you haven’t already read it, I recommend Jennifer Egan’s award winning novel, “A Visit from the Goon Squad”, set in the current music industry world, largely from the perspective of an aging rock & roll executive. Besides the changes in both the music and healthcare industries, many due to technology, I think real docs and real musicians have something intangible in common. For lack of better words, I’ll call that intangible quality heart and soul. We all know it when we experience it and I wouldn’t want to live in a world without it.

  • Dr. Drake Ramoray

    “There is little ownership of patient care any more. Instead, residents recite guidelines, click some buttons, and follow rubrics instead of appreciating the complexities of patient care.”

    Sounds like they are being appropriately prepared for the future vision of primary care as pushed forth by most medical societies, pharma, insurance, hospitals, and our pay for performance overlords.

    There was a post on here some months back with the reading list for residents. A huge portion of it was lean six sigma BS. The medical profession is so lost.

    *Well, I think I have gotten the “get off my lawn!” out of my system for today.

  • RuralEMdoc

    Sim lab deliveries!!!!!!

    It’s the new hotness.

  • DeceasedMD1

    Future doctors learning to be fake with fake patients. Very impressive.

    The last medical student piece I read here, he told me there were classes on “how to communicate” with patients. No doubt taught by an expert admin.

  • guest

    I hated being tested this way in med school. I did learn something however and that is how to complately fake compassion and appearance of being a good listener under pressure. Pure acting. It is cool, it is popular and in my opinion just one more activity designed to waste our time, like much of med schooland medicine in general these days.

    • DeceasedMD1

      Sounds like Murphy’s Law. “The secret of success is sincerity. Once you can fake that you’ve got it made”. Seriously that sounds absurd. But after graduating you might be ready for Hollywood. I am sure you are a pro now at “acting” like a doctor. ( I have no doubt you are a good MD so just a joke more than anything about the fakeness of that aspect of your training.)

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