Month: February 2011

Why you want a medical student to care for you

Amid the buzz about whether medical students should be sued and the bill currently debated in Arizona (a state which finds itself in the spotlight more than usual these days), I noticed some commentary from several people who do not think they would like a medical student on their case.  Sometimes patients do refuse to be cared for by medical students, often due to overestimating the involvement they will have in their care.  Indeed, there is an inherent tension between patient safety and the need to train future physicians.  However, it is important to recognize there having a medical student caring for you may actually be a blessing in disguise.  There are several reasons why you may benefit from having a medical student caring for you. 

  1. You will have a complete history and physical on your chart– There is often not enough time for a resident or attending to do a thorough history or physical.  Their documentation is not likely to be as complete as a medical student’s.  Interestingly, the best friend of every consulting physician is the “medical student H&P” – the history and physical document that details all the major information about a patient’s stay.  While patients often report they are ‘repeating’ their story to everyone they see, part of that is due to an incomplete history that necessitate treating physicians to delve a bit more to confirm the diagnosis.   Unfortunately, with the advent of electronic health records, medical student histories are sometimes not part of the medical record.  However, it does not  have to be the case.  At one of our community hospitals, our students notes do appear in the system and are able to contribute to the care provided.
  2. Someone will check in on you frequently and have time to listen to your questions – Because medical students don’t often have the caseload of the resident or attending, the student is able to pay more attention to you throughout the day.  A third year student may be following only one or two patients at a given time.  While it is true that maybe they don’t know all the answers to your questions, they can relay this to your team and often serve an invaluable role.
  3. They may make you feel better– Students are often less burned out and more connected to their patients since they are learning from each of their interactions.  I’ve had students who really connect to patients through a variety of ways to help them heal, including reading to them or bringing them their favorite magazines or books so they don’t get bored.
  4. You may get fewer tests – While it may appear that a medical student may be associated with more testing, the truth is that the job of the medical student is often to ‘get old records’ from the outside hospital or the primary care physician.  Unfortunately, this is very time consuming and hard to do and it is not easy to “check the record” as patients often ask us to.  Maybe this will get better with electronic health records that talk to each other, but in the interim, we rely on our students.  Unfortunately, residents do not have time to do this these days with the caseloads they carry.  For example, last year, I had a medical student who secured the invaluable bone marrow biopsy on a patient from an outside hospital on a weekend(!) that saved the patient from getting an unnecessary and painful procedure.  A few weeks ago, I had a medical student who secured a bevy of rheumatologic and hematologic labs on a patient with a suspected autoimmune process which saved us from having to redraw all of those tests.
  5. A student may actually make the diagnosis– Students are sometimes assigned to the ‘bread and butter’ cases (routine stuff) but are occasionally assigned to the ‘zebra’ – the interesting case that no one can figure out.  While students don’t have all the experience that their more seasoned and older residents and attending have, they do have time to look things up and can sometimes make a breakthrough since they keep a wide open list of possibilities.  Over the past few years, I can recall several instances in which a patient’s diagnosis was a mystery and a massive workup was ongoing with multiple consultants involved.  In two instances, a student offered the correct diagnosis early in the patient’s course and found key literature to secure getting the right test.  In another case, a patient who was in the hospital became very concerned about her nail findings (which was her number one complaint) despite having a serious heart infection.  After some digging, our student figured out the diagnosis was Muerkhe’s nails, which is a finding associated with low protein, and he was able to reassure her that they would go away as her nutrition improved.

While some of you may still have concerns, it’s important to know that students are closely supervised by residents and attending, who are the ones responsible for your care.   In fact, the patients cared for by students sometimes get more attention during rounds by the resident and attending.  So if you or a loved one find yourself in a teaching hospital, consider asking for a medical student on your case.

-Vineet Arora, MD


The Film Clerk, the Radiologist & Technology: Friend or Foe?

During my last two weeks on service, whenever we ordered an MRI or a CT, I wondered was this scan necessary and will it really change care?  In addition to increasing scrutiny on the perils of unnecessary radiation, the blogosphere was abuzz about this topic (see Bob Centor and Bob Wachter among others).  Coincidentally, our grand rounds speaker last week was Dr. Bruce J. Hillman who is the chief of the Journal of the American College of Radiology, and recently coauthored a book on the subject titled the Sorcerer’s Apprentice: How Medical Imaging is Changing Health Care.  

Many of Dr. Hillman’s observations were spot on – radiologists hedge – they overcall things due to concerns they will miss something.  An overcall is better tolerated than a miss.  As a result, many patients are diagnosed with incidentalomas or pseudodisease that could lead to other costly workups and expose them to unnecessary radiation.  How can a clinician ‘ignore’ the overcalled incidentaloma in the world of malpractice?  Dr. Hillman also spent a lot of time discussing the overreliance on scanning in teaching hospitals.  In the busy overworked environment in many hospitals, it is easier to get a scan than do a thorough history and physical exam.  (This is assuming that physical exam skills are actually good enough to pick things up). 

Unfortunately these days, residents actually have LESS time for history and physical.  With duty hours, the chance they actually met a patient on admission and obtained the history is lower.   There is also less time to make a decision.  With pressure for shorter length of stays coupled with system inefficiencies, if you’re not in the queue the day before for the imaging test du jour, you will add on an extra day just to get the test.  Lastly, while fear of litigation does play a role, physicians also worry about backseat quarterbacking and looking bad in front of peers.  For example, I often thing to myself, if this patient comes back to the ED with the same complaint, would those physicians think I was crazy for not getting a scan?   Because imaging often helps make the right call, the question is when is it appropriate or inappropriate? 

This is when radiologists have traditionally come in.  When I was a resident, I recall going down to radiology and asking the film clerk to get my films (in fact, being friends with the film clerk was as important as being friends with the nurse).   After waiting patiently in line in the dark room for the next available radiologist in the specialty of interest, I ‘presented’ the patient with a one liner and the specific clinical question.  The radiologist would then reread the films and discuss the case, often asking for more questions.  At the end of this conversation, I often had a plan which usually did not involve another scan.   

While technology has replaced our trusty film clerk as our greatest friend, it has also become our worst enemy.   Today, I can look at images on the computer, even on the iPads that our residents carry on rounds, and eagerly await the ‘final read’ by the attending.  Ordering tests has also become easier.  Most of my time as an intern was spent calling down to radiology convincing them I needed the test.   That is in sharp contrast to today when orders are just entered electronically with a drop down selection of ‘reasons’ that include ‘r/o pneumonia’ or ‘dyspnea’ (fancy medical term for shortness of breath).  No wonder most of the reads come back as “suggest clinical correlation.”  

So, how do we fix this? Well, Dr. Hillman highlighted the need to start early in training – essentially to teach students and residents to do this better.  So, this past week at a curriculum meeting, I was pleased to learn that one of our expert radiologists would be formally integrating radiology into our third year IM clerkship, including costs of testing and appropriateness of tests.  However, we all know this will not change anything if the faculty are pushing for the scans.  Professional organizations have recognized this, and started to offer guidelines for practicing physicians.  Earlier this month, the American College of Physicians released guidelines calling for internal medicine physicians to minimize scanning for low back pain.  The American College of Radiology has released  “appropriateness” criteria for a variety of clinical conditions which include the radiation risk for each test.   Since faculty may or may not see guidelines,  Massachusetts General Hospital has gone one step further, embedding these criteria into the electronic ordering system for radiology testing as a hard stop, which offers suggestions for low yield exams and require that a physician override the system to proceed.  Indeed, technology can be a better friend.  Perhaps, another solution is to talk to our old friend the radiologist.

-Vineet Arora, MD

Student Doctor or Medical Student? And Other Teaching Hospital Names

I recently saw a post in Yahoo questions entitled, “Is it illegal for a medical student to introduce themselves as “Doctor” before they have received their MD?”  One of the answers that was rated highly was “I think it is more unethical than illegal.”  Clearly, if a student is deliberately misrepresenting themselves as a ‘doctor’, it is grounds for disciplinary action.  More often than not, this misrepresentation is not deliberate on the part of the student.  For example, some of our prior work demonstrates that medical students often report that they were introduced by other physicians as a doctor to a patient and that to a lesser extent, students may not correct someone who mistakes them to be a doctor. 

Complicating matters is the propagation of the term “student doctor” at some institutions which is especially problematic.  After all, how many patients will be quickly discern that ‘student doctor’ actually refers to ‘medical student’ and not a ‘doctor’?  Unfortunately, patients who hear the term ‘student doctor’ may not hear the term ‘student’ and just zero in on the ‘doctor’ part, as they often wait patiently for their doctors to see them in the hospital.   This brings us to the problems of how doctors are named in teaching hospitals.  The system could not be more confusing.  

  • Interns – This is probably one of the most confusing terms in a teaching hospital.  Interns are doctors who have graduated medical school and are in their first year of a residency training program.  Of course, ‘intern’ is also the universal term for all those college students trying to get a short term experience on their resume by ‘interning’ there first.  So, why would a patient think an intern is a doctor?   After all, you would never put your faith in the legal ‘intern’ at the law firm to defend you in a lawsuit.   To make matters worse, there is the opposite problem.  Intern is often mistaken for ‘internist’, who is actually a doctor who has completed their internal medicine residency and otherwise a ‘doctor for adults.’  (Patients are more familiar with their “PCP” or ‘primary care physician,’ which could refer to either an internist or a family physician).    
  • Residents – Residents can refer to any doctor who has graduated from medical school and is in a residency training program (including interns). The term “residents” originates from William Osler’s era when residents did live in the hospital.  Of course, they don’t live there anymore  which would violate worker’s rights not to mention their regulated duty hours… but we still call them residents.  The other name residents are often referred to is as “PGY1” (post graduate year) which is certainly not an improvement.  
  • Housestaff – One of our premed college students just asked me what this term was this week.  I explained that while this does sound like the butler, maid, or cook a fancy estate, this term actually refers to the hospital as the “house” that the residents live in as the staff.  So all residents (including interns) are part of the ‘housestaff’. 
  • Fellow – This is perhaps one of the most disconcerting names for a physician as it may sound like it refers only to male doctors (and conjure up images of young man from England with excellent manners i.e. he’s a fine ‘fellow’).  In fact, a fellow is a doctor who has completed residency and is getting advanced training in a certain subspecialty. 
  • Attending– Attending to what you may wonder?  The attending physician is actually the doctor who has completed training and is legally responsible for the care provided by residents.  In other words, this is the ‘boss’ doctor as my residents sometimes introduce me to the patients on our team. 

A few years ago, we tried to improve the situation for our patients by having doctors introduce themselves with baseball cards with their pictures on the front and the roles of the doctors were displayed on the back.  While we were able to increase the percentage of patients who knew who their doctor was, we were surprised to discover that fewer patients stated they understood the roles of the doctors.   How did we make it worse?  Perhaps ignorance is bliss.  By trying to unlock the secrets of these names, patients realized the names we use in teaching hospitals are confusing.

However, this confusion is more than just a name, it is also a patient safety issue.  After 18 year old Lewis Blackman died in a South Carolina teaching hospital without an attending evaluation when his family kept asking to see the doctor, a new law in his honor aims to address the issue.  It requires that patients receive written materials describing the roles of the trainees on their team and also how to contact the attending if they have a concern.  More recently, the ACGME, which accredits US residency programs, has included a mandate in its now infamous policy restricting resident work hours that states “residents and faculty members should inform patients of their respective roles in each patient’s care.”  While it is not certain how this will be implemented at every teaching hospital across the land, it’s certainly time to make our naming system easier and more transparent for patients to understand.

 –Vineet Arora, MD