Dear Director: Our local medical school contacted me and asked if we’d be able to take physician assistant and medical students for rotations in the ED. It seems like they’re offering us free labor, so I wonder what the pros and cons are of having them in the ED?
“Show me a BMS who only triples my work and I will kiss his feet.”
House of God Law XI
from The House of God
by Samuel Shem, MD PhD
The emergency department presents tremendous opportunities for students. We have a never ending patient population, a mix of normal and abnormal physical exam findings, and the opportunity to learn minor bedside procedures. But there is obviously more to factor in than what students can learn.
Starting Out
I’ve spent most of my career in community teaching hospitals. Adding students or residents to the mix will be a mixed blessing. For many docs, the opportunity for bedside teaching can add enjoyment to the daily grind of seeing patients. Some may be re-energized when pushed to answer questions for things we don’t typically think about. For others, the added pressure or interaction could be an additional stress.
One of the biggest advantages of providing education through the ED is the advantage you may get in recruitment. This is particularly true when you have EM residents or advanced practice provider (APP) students, such as a PA or NP student, rotate through your ED. You really know what your getting (as does the student) after a month long rotation in the ED. And I’ve been on the losing end before, having lost several EM recruits to another facility because they rotated there as a resident and felt “comfortable” with the EMR and their new future colleagues.
Before bringing on anyone for regular rotations, you need to have someone who will be the education coordinator. This ranges from interaction with the schools, providing orientation, creating the schedule (don’t put students with docs who aren’t going to teach or supervise), doing assessments (and occasionally writing letters of recommendation), and making sure the students/residents are achieving their learning objectives. This sounds like a lot of work, and to do it right, it probably is.
Dr. Bob was the best at doing this that I’ve worked with. He always went the extra mile for the residents to make sure they learned, which led to them appreciating the job we do in the ER that much more. His suture lab was a resident favorite and included him getting pig’s feet from the local butcher. While I’ve been offered payments by schools to take students, I’ve also been offered to “buy” resident hours, but most of the time there hasn’t been any revenue gained or lost. You need to consider the EDs patient population, how they’ll respond to an additional layer of provider care, what impact that will have on your flow (and any associated metrics), and most importantly, how receptive your current providers are to supervising and teaching.
Residents
Is there anyone who would turn away a senior emergency medicine resident from rotating in the ED? They would be fairly independent, provide good care, challenge us with questions so that we push ourselves to learn and keep up, and perhaps even show some of us a thing or two about new meds or techniques. Of course, my former residency isn’t offering to send me senior residents. At most of the places I’ve worked, I’ve had transitional interns or first- or second year medicine residents rotate through the ED. These people can be fun from a teaching perspective, but they also require close supervision and can impact flow. When you work in a teaching hospital, I think rotating in the ED helps the residents understand the job and push to move patients. It’s good for forming relationships that typically pay dividends down the line. As mentioned before, having an EM resident rotate in the ED may give a recruitment edge and having an IM resident may also pay dividends down the line, particularly if they stay in the hospital to work as a hospitalist or join a practice in the area after graduation.
Medical Students
The best medical student that I ever had rotate with me had been a PA I worked with for seven years prior to medical school, and she made my life much easier. On the other hand, I can remember sending a med student in to see a patient and going to check on them when they hadn’t come out of the room for 30 minutes, only to find the student obtaining the history while the patient was in florid pulmonary edema and needed to be intubated. The first student required little supervision while the second student obviously required much more than I was giving at that particular time.
As rotations in emergency medicine have increased, either due to popularity or because they’re required by the school, schools have looked farther and wider to rotate their students. And while having a fourth year med student do an elective in the ED sounds like it could be helpful to us, as one of my colleagues reminded me, the students going in to emergency medicine are not rotating at community hospitals, but rather at the academic center where they want to do residency. So the motivation and quality of the student you might see in a community hospital may not be the same. Again, you’ll need to consider the facility that you’re in. If you’re in a teaching hospital where patients and nurses are accustomed to students, the allowance for extra time may not have the same negative consequences when compared to a highly-functioning, ED run by attendings where patients would be appalled to have a med student involved with their care.
When I’m starting with a new student, I find it best to direct them to patients that I’ve already seen and expect to be in the ED for some period of time. I’ll ask the patient if they mind having a med student come do their history and physical. I’ve rarely run into a problem, as the patient knows their work-up is getting started, and they typically like the interaction with the med student.
Mid-Level Students
I’ve had the most success recruiting great providers by hiring residents I’ve worked with when I was a part-time academic attending and also by having PA students do an elective in the ED with an experienced PA. While a PA student is similar to any other student in that their care will be slower than an experienced provider, I’ve found that with the right mentor, this impacts a Fast Track component of the ED less than when med students rotate on the acute side. Perhaps it’s because the patient work up is less extensive, but I also think one of the secrets is to not only have a fast, experienced PA supervising the student, but that the lead PA also has an established connection to the school. That way, they can help to get the best students who are not only interested in emergency medicine, but are also interested in staying in the area and working at your site. What better way is there to recruit than to give a student a one-month audition with on-the job training? Even if their medicine is at a student level, you can observe their work ethic and how they communicate with staff and patients. You can also see how quickly they learn and improve their skill set.
Conclusions
Having students and residents rotate through the ED can add a new energy to the department and be personally rewarding for the attendings and other supervising staff. It can also enhance recruiting efforts and, if nothing else, help build relationships with other non-ED physicians. On the other hand, there can be a negative impact on flow metrics and patient satisfaction, so as the department leader, you need to be prepared to minimize that impact. Having the right liaison in place who is committed to education is critical.
