I kept a blog in medical school. Once, during third year, I wrote: "An article recently published in NEJM, "Into the Water," touches on this aspect of third year—not knowing the etiquette. The article focuses on how we learn to cope with the emotions that come with medicine. Specifically, it discusses the range of reactions to illness, and the ambiguity of what is appropriate, as demonstrated by residents." The article reminded me that several aspects of our training deserve clarification, including the student-teacher relationships. We assume that, as we climb the ladder of medical training—from premed to MS1 to PGY1 to attending—we'll acquire clarity along the way. At some point during our professional lifespans, we will transition from student to instructor. We're just not sure exactly when. Or how... In the past few years, academic medicine has turned its attention to capacitate residents to teach medical students. As the freshest graduates, we have the most immediate memories of what medical school was like. In theory, that makes us the best people in the hospital to empathize with students, recognize their needs, and understand how to teach them. That said, we also have the least practice in educating them. How can we learn to be teachers when we ourselves are still training? Should we have learned that too when we were in our own clerkships? I've always thought that education happens in two phases. Here I use the medical student example, but it seems true in other contexts as well. Phase 1: The Initiation If an MS3 is a candle, the resident strikes the match. In other words, the resident is first there to welcome them. Medical students come to clerkships with all of the raw material necessary to become a doctor. They can think scientifically. They have a decent work ethic. They're dedicated to patients. They have successfully jumped through all of the academic hoops it takes to get to this point. Now, the resident/teacher's first task is to start the process of becoming a physician within a hospital. For many medical students, this short phase is critical. This is the point when the student finds a role model, as well as the affirmation that they are capable of achieving that status themselves. Phase 2: The Inertia Now that you have kindled your third year's rite of passage into the rotation, your job is to be a guide. The resident teaches students how to apply their didactic knowledge to clinical decisions, to navigate a hospital's protocols, or even to learn basic surgical techniques. You can't give a student 'hands," but you can teach her how to use them to tie a surgeon's knot. This is not simply giving simple knowledge or skill to your student; it implies development, movement, and direction. This is the aspect of teaching that spawns personal and professional growth. Imagine a coach who gets his athletes to surpass even their own expectations. It's kind of like that. Easier said than done... How and What Do Students Learn on Clerkships? In multiple studies, medical students report that up to one third of their education on clerkships is provided by residents.[2-4] Accrediting bodies, including the Accreditation Council for Graduate Medical Education (ACGME), recognize this and encourage "Resident as Teacher" (RAT) training programs for house staff of all specialties. The design and quality of RAT programs vary, with no criterion standard. Then again, in education, one size does not fit all. In their 2014 evaluation of RAT programs, Karani and colleagues[5] described the following seven domains that third year medical students identified as helpful resident teaching methods[5]: Role-modeling Focusing on teaching Creating a safe learning environment Providing experiential learning opportunities Giving feedback Setting expectations Stimulating learning In terms of what the students learned, the study reported nine main themes: Patient care Communication Navigating the system Adaptability Functioning as a student/resident Lifelong learning General comments Career/professional development Medical content The authors note in their paper that, in regard to RAT programs, "models are based on teaching behaviors of distinguished clinical faculty, derived from observations of faculty, or designed for use by faculty in encounters with residents. None of these models focus on the content students actually learn from resident teachers or include behaviors specifically identified by students as being effective teaching strategies used by excellent resident teachers." In another study at Johns Hopkins,[6] a survey of almost 100 fourth-year students ranked the following top four experiences (out of 55 listed) as having the most profoundly positive impact on their learning environment: Working on a highly functional clinical team Encountering inspiring role models Feeling that I contributed positively to patient care Working with enthusiastic and motivating teachers It's not surprising that we see the value of role models and teachers, as well as the importance of a functional resident team. Rather than specific medical knowledge, skills, or interactions with fellow MS3's on clerkship, medical students thrive on positive relationships with mentors. In an ideal, straightforward world, we residents could provide each medical student with a standard package of all seven teaching methods that are helpful. They would, in turn, master all nine aspects of patient care, communication, system navigation, and so on. But, like most things in healthcare, this isn't ideal, or straightforward. Although managing medical students requires fine-tuning for each individual, some behavior patterns have emerged in my experience. In these situations, I've found the following advice helpful. The overeager-ist Sometimes a delight to work with, sometimes a bit much... As one senior resident at the University of Pittsburgh, Dr Woody Chang, suggests, "Always try to give them as much work as you can, but also keep them focused on learning what's important. I find that the overeager students tend to do so much reading that they miss basic logistical stuff like discharge. I try to bring up something new with them every day so that they stay sharp." The un-enthusiast It's difficult to address a motivation deficiency. The most sensible solution would be to identify the source of disinterest. I like to take a few minutes at the end of the first week of a clerkship and debrief with each student privately. It's a good time to ask: What they hope to get out of the rotation (maybe they aren't getting it) What they felt went well, and what they wish had been different (helpful to know) It's also a chance to give specific critiques or goals. For example, "I'd like you to be able to write your progress note in 10 minutes by the end of next week. We can go over how to streamline notes on Monday morning." Finally, it is a chance for them to get to know you and possibly to form a more personal connection. If after the second week they are still not thriving, it's a good time to talk with the attending and the team about what to do next. The intimidated student Aren't we all a little awkward sometimes? This is a big role model moment. Students who aren't comfortable in certain clinical scenarios—delivering babies, for example—can benefit immensely from a private pep talk: "It's completely normal. When I was a med student, I was nervous about [xyz]." Obviously, don't force them. Invite them to do the task with you. Be their ally. Encouragement and teaching go a long way. A Few Notes on Boundaries In general, most residents agree that it's good to be friendly with medical students. It creates comfort, open communication, and a safe learning environment. Still, professionalism is always important, especially given the aspect of role-modeling. Besides issues related to residents and medical students socializing outside of the hospital (maybe) or residents having romantic relationships with med students (no), mindful communication is also critical. Subtleties like appropriate text messaging should be handled thoughtfully. For example, texting a student when he is not working could cause unnecessary stress. Already a Team Member Finally, remember that MS3's are more than students or even potential future colleagues; they are already a part of your team. During our discussion about medical students, Dr Chang relayed this story: "When I was an intern, I was supervising a patient whom we admitted for bilateral lower extremity pain and found to have calciphylaxis via leg x-ray. I had a medical student who was interviewing the patient after I had come over to check in for the afternoon. He came back to me and said that something was wrong... I couldn't believe it because I had just seen the patient and she seemed fine; she just said she was a little tired. When we both went back, we had discovered that her entire arm was numb. We called a stroke code, and I later found out that she had an ischemic stroke... The med student really helped save her life." Source
