Practical tips and/or guidelines
Open Access

Duties and Conduct of Medical Students

Behnam Molavi[1], Ali Mir[1], Abolfazl Shojaiefard[1], Shirzad Nasiri[1], Ali Ghorbani Abdehgah[1], Ahmadreza Soroush[1]

Institution: 1. Tehran University of Medical Sciences
Corresponding Author: Dr Ali Ghorbani Abdehgah ([email protected])
Categories: Education Management and Leadership, Medical Education (General), Students/Trainees
Published Date: 09/06/2016

Abstract

The regulations regarding the expected conduct of medical students in Shariati hospital’s surgery ward have not been updated to match current day standards. Working hours are always discussed in light of the patient's wellness versus the physician’s fatigue, however, there is no study about the effects of working hours on medical education. Medical students work 8 hours per day and they are encouraged to attend morning classes after finishing their "on-call" shifts. Instead of learning in class, they should study their educational material on their own. “On call" students may remain in the hospital to attend classes. However, no more work should be expected from these students. The working hours should be scheduled to enhance the students’ learning and to strengthen the medical educational environment. The faculty should consider the safety of the students in their policies. Medical students should wear comfortable and appropriate clothing, including white coats. Students should be viewed and treated as members of the surgical team. Students should be asked to prepare and present a 15-minute report in the journal club. Moreover, they should participate in all seminars and educational programs. Finally, medical students have a flexible curriculum in the surgical ward, and these regulation are subject to change according to circumstances.

Keywords: ; medical education; clerkship; student assessment; safety; curriculum

Introduction:

Introduction:

A medical doctor must have a variety of skills and abilities(Miller, 1990). Therefore, medical students should be trained in a complex health care setting with a variety of patients and public expectations. Clinical skills must be learned by energetic, functioning, and effective experience in patients care at the bedside or in the office.

The attending physician must help the students learn basic knowledge of anatomy and physiology as they acquire the skills of patient assessment and management(Steadman et al., 2006). In order to provide an appropriate service for patients and to intensify the medical education of students, the working hours should be organized to create harmony and balance between clinical experience, health care service, and academic success(Lockley et al., 2004).

Duties and Hours:

In different institutions, medical students arrived at the hospital at different times in the morning. The most common time of arrival was reported to be 7 am (Boone, Stone, Perkins, & Taylor, 2015; Pang, 2012). Since Shariati hospital’s patient rounds start at 6 am, it was recommended medical students to join the residents and interns at that time. This can become an important part of their education; they can learn how to prepare medical reports, and they can see the patients' treatment and recovery processes.  Medical students worked 8 hours per day, with 2 hours for patients’ turn over. Total working time should not exceed 10 hours each day. During "on-call" days, the maximum continuous working hours should not exceed 26 hours (13, 2014; Committee; Pang, 2012). We expect that medical students should complete their medical responsibilities even if it takes longer than their working hours. This policy increases the students' clinical experience (Pang, 2012).  It is necessary to have sleeping quarters for medical students. If there are no such facilities in the hospital, “on-call” students should end their work around 11 pm. Being "on-call" is a major part of the medical student's education. It increases their experience in a 24-hour period. Students are expected to be "on call" 6 or 7 days per month. Exemption is given for one or two days before exams. The students are encouraged to attend morning classes after finishing their "on call" shift. The students are responsible for studying their educational material on their own (Pang, 2012). Expecting mothers are not given "on call" duties after 27 weeks’ gestation and night shifts after 31weeks’ gestation. Moreover, maternity leave is granted for 52 weeks (Pang, 2012).   Although working hours are always discussed in light of the patients’ wellness (Fletcher et al., 2004; Landrigan et al., 2004; Lockley et al., 2004) versus the physicians’ fatigue, there is no study about effect of working hours on medical education. More research should be done to study the relationship between working hours, patients’ wellness, and students’ learning capacity and health. This research will guide medical schools to improve the medical education system (Pang, 2012).  Medical students should hand over the patients to the next "on call" student. If a student misses a class, they are responsible for obtaining the course material from other students. "On call "students may remain in the hospital to attend classes. No more work should be expected from this student (Pang, 2012).   If a student stays "on call" during a holiday (for more than 8 hours), they should have an "off" day in the same work rotation and not in the following rotation.  The students should not be "on call" on the last night of their rotation. The students should return to the ward after their exam if their rotation is not finished (Pang, 2012).

Observation and Feedback:

Medical schools should always review, strengthen, and inspect their procedures(Christie & Merton, 1958).  Working hours, responsibilities, and expectations from students, especially after ending their "on call" shift, should be clearly explained to them. The working hours should be scheduled to enhance the students’ learning and to strengthen the medical educational environment.  Monitoring these policies is the responsibility of the clerkship director in each ward, head of the ward, department manager, and deputy dean. If it becomes evident that a student is overworked, the deputy dean or clerkship director should correct the matter (Pang, 2012). 

Personal Safety:

Medical schools should consider the safety of the students in their policies. For instance, taxi fare should be given to those who finish their shift after 11 pm. If a violation is found regarding the on-call policy, students may notify the clerkship director. If the issue is not resolved, the clerk may notify the deputy dean and ultimately the clerk can notify the undergraduate medical education appeals committee (Pang, 2012).

The students should be protected against dangers and should be provided with a comfortable work environment, including personal lockers, resting spaces, safe commute, safeguarding of their personal information, protection against workplace violence, protection against occupational hazards including radiation and dangerous chemicals, and the high quality indoor air (Committee).

The students should be fully informed about policies and procedures of the medical center. They should also be informed about dangers in the workplace. They should be trained on avoiding, managing, and reporting violence, harassment, and intimidation (Committee). They must be provided with written guidelines and trained regarding exposure to dangers involved in each medical center (Committee; Pang, 2012).

On site specific orientation sessions should be conducted and the students should be evaluated for appropriate understanding prior to engagement in activities which may involve exposure to hazardous materials and dangerous situations (Committee).      

Dress Code:

White coats should be worn at all times. Wearing undershirts, T-shirts, jeans, sport pants, stretch pants, sandals, and open– toe shoes are not allowed. Professional appearance is an important issue. Medical students should wear comfortable and appropriate clothes. They are expected to have the highest standard of professional appearance at all times ("Dress Code for USA COM Medical Students," 2014; Hammer, 2000). The dress code is related to infection control and social concerns. Professional appearance helps medical students to achieve their professional role in the society(Gherardi, Cameron, West, & Crossley, 2009). In order to prevent the spread of infection among patients and in the food preparation areas, artificial fingernails are not allowed. Natural nails should not be more than 6 mm long. Tattoo and body paints are not allowed. Medical students should adhere to the highest standards of cleanliness. Their beard and mustache should be clean and trimmed. The use of perfumes and fragrances is not allowed since they may cause distraction and allergic reaction in patients. Jewelry should be small and should not interfere with medical practice. Sharp jewelry, except for earrings, should be removed or hidden. Smoking and chewing tobacco are strictly prohibited. While on duty, the use of identification badges and white cats are mandatory at all times.

A study has shown that wearing the badge on the right side allows patients to see it better during a handshake. 

Curriculum:

Medical students shall assist the assigned physician during routine visits, and help to prepare for the initial evaluation of the patient and develop an initial management plan.

At the end of the elective rotation, the attending physician should give the student complete verbal feedback. A medical education tracking system and student-patient list should be completed. The course director should review, in the middle and at the end of each rotation, the above information and provide a report to file and to the student. In all wards, there should be a file containing the name of the program coordinator, duration of rotation, number of students, date of acceptance, and program objectives in full detail. For example, in the surgical ward, the objectives of the educational course should contain selected surgical procedures in general surgery or in specialty surgery including preoperative, intra-operative, and postoperative patient care.

Medical students have a flexible curriculum in the surgical ward. The students select their program according to their educational experience in general surgery or specialty surgery. The students are under the direct supervision of the staff physician and the senior resident in each department. The students attend to patients in the clinic, before the operation, after the operation, and during admission in the ward. The students should be viewed and treated as a member of the surgical team. Chief residents or staff members should evaluate the students' performance using standard forms given to the dean or phase coordinator on request. The students should be asked to prepare and present a 15-minute report in the journal club.

The students are expected to participate in all seminars and educational programs. They must perform activities, including pre-rounding on assigned patients, writing daily notes, and being present for both morning and afternoon rounds with the chief residents.

The students should never use their personal telephone to contact the patients. They should keep the patients’ confidentiality and should report mistreatment and other types of unprofessional behaviors (Committee).

Disciplinary actions against the students should be coordinated with students’ supervisor. Initially, all mistakes made by the students and dangers faced by them should be handled and resolved locally; otherwise, the matter should be reported to the appropriate committee and faculty (Committee). 

Conclusion:

Having a structured and established educational program encourages the medical students to regularly participate in medical research and treatment activities and will prepared them for accepting critical responsibilities in the future. Excessive or lenient procedures should be avoided when preparing a medical program. 

Take Home Messages

 

  1. Structured educational program enhances the quality and quantity of education
  1. The faculty should consider the safety of the students in their policies
  1. Medical students should wear comfortable and appropriate clothing, including white coats
  1. Medical students should participate in all seminars and educational programs.
  1. Medical students should have a flexible curriculum in the surgical ward, these regulation are subject to change according to circumstances

Notes On Contributors

Behnam Molavi: assistant professor of vascular surgery, Director of education of surgical students in Shariati hospital

Ali Ghorbani Abdehgah: assistant professor of thoracic surgery, Director of surgical education in Shariati hospital

Abolfazl Shojaiefard: assistant professor of vascular surgery, administrator of Research Center of Surgical Outcomes and Procedures

Shirzad Nasiri: associate professor of surgery, Director of education of surgical residents in Shariati general hospital

Ali Mir: assistant professor of surgery, Director of Surgery journal club sessions in Shariati general hospital

Ahmadreza Soroush: professor of surgery, the chief of surgery in Shariati general hospital

Authors declare no conflict of interest. 

Acknowledgements

The authors would like to thank Mr Amirmohammad Ghorbani Abdehgah for his assistance in editing the manuscript.

This work was an academic collaboration. No funding was received for it.

Bibliography/References

13, F. E. C. J. (2014). Clerkship Duty Hours Retrieved from http://umanitoba.ca/faculties/medicine/education/undergraduate/media/Clerkship_Duty_Hours(1).pdf
 
Boone, D., Stone, C., Perkins, C., & Taylor, C. (2015). Clinical Clercship Surgery Handbook.
 
Christie, R., & Merton, R. K. (1958). Procedures for the sociological study of the values climate of medical schools. Academic medicine, 33(10), 125-153.
 
Committee, U. M. E. E. Standards for call duty and student workload in the Clerkship Retrieved from http://wbacademy.utoronto.ca/wp-content/uploads/Standards-for-call-duty-and-student-workload-in-clerkship_revised-2013-01-15.pdf
 
Committee, U. M. E. E. UME Trainee Health and Safety Supplemental Guidelines – Personal Safety and Occupational Hazards Retrieved from http://www.md.utoronto.ca/Assets/FacMed+Digital+Assets/Undergraduate+Medicine+Education+MD+Program/Policies+$!26+Guidelines/UME+Trainee+Health+and+Safety+Supplemental+Guidelines+$!e2$!80$!93+Personal+Safety+and+Occupational+Hazards.pdf
 
Dress Code for USA COM Medical Students. (2014). Retrieved from https://www.usahealthsystem.com/workfiles/com_docs%2Fstudentaffairs/DRESS%20CODE.pdf
 
Fletcher, K. E., Davis, S. Q., Underwood, W., Mangrulkar, R. S., McMahon, L. F., & Saint, S. (2004). Systematic review: effects of resident work hours on patient safety. Annals of internal medicine, 141(11), 851-857.
http://dx.doi.org/10.7326/0003-4819-141-11-200412070-00009
 
Gherardi, G., Cameron, J., West, A., & Crossley, M. (2009). Are we dressed to impress? A descriptive survey assessing patients' preference of doctors' attire in the hospital setting. Clinical medicine, 9(6), 519-524.
http://dx.doi.org/10.7861/clinmedicine.9-6-519
 
Hammer, D. P. (2000). Professional attitudes and behaviors: the" A's and B's" of professionalism. American Journal of Pharmaceutical Education, 64(4), 455.
 
Landrigan, C. P., Rothschild, J. M., Cronin, J. W., Kaushal, R., Burdick, E., Katz, J. T., . . . Bates, D. W. (2004). Effect of reducing interns' work hours on serious medical errors in intensive care units. New England Journal of Medicine, 351(18), 1838-1848.
http://dx.doi.org/10.1056/NEJMoa041406
 
Lockley, S. W., Cronin, J. W., Evans, E. E., Cade, B. E., Lee, C. J., Landrigan, C. P., . . . Stone, P. H. (2004). Effect of reducing interns' weekly work hours on sleep and attentional failures. New England Journal of Medicine, 351(18), 1829-1837.
http://dx.doi.org/10.1056/NEJMoa041404
 
Miller, G. E. (1990). The assessment of clinical skills/competence/performance. Academic medicine, 65(9), S63-67.
http://dx.doi.org/10.1097/00001888-199009000-00045
 
Pang, R. (2012). Clerk Duty Hours A Student-Centered Review Canadian Federation of Medical Students - CFMS. Retrieved from http://www.md.utoronto.ca/Assets/FacMed+Digital+Assets/Undergraduate+Medicine+Education+MD+Program/Policies+$!26+Guidelines/UME+Trainee+Health+and+Safety+Supplemental+Guidelines+$!e2$!80$!93+Personal+Safety+and+Occupational+Hazards.pdf
 
Steadman, R. H., Coates, W. C., Huang, Y. M., Matevosian, R., Larmon, B. R., McCullough, L., & Ariel, D. (2006). Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills*. Critical care medicine, 34(1), 151-157.
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Appendices

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Reviews

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Emma Jones - (27/06/2016) Panel Member Icon
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This paper details the expectations of medical students placed at Shariati hospital’s surgery ward. I believe it could be a valuable resource for all doctors who have medical students placed on their team. It provides a very detailed description of what is expected of the students which is very beneficial as often the ward doctors and medical students themselves are often not sure how much time to dedicate to ward duties and how much to allocate to study.

Often busy medical or surgical teams perceive engaging the student as another job which will take up time, rather than adopting the student into the team as someone who can make a valuable contribution to patient care. In this paper the students’ role within the team is clearly outlined which will hopefully facilitate engagement and adoption of responsibility within the team.

Many features of this program will prepare the medical students for working life – such as being on call and running pre-admission clinics. The paper does not address theatre specific guidelines for the students such as the number of surgeries they should scrub into per week, or a logbook for practical procedures.

The paper mentions the importance of identifying whether the student is “overworked”. Specific indicators that a student is overworked may help doctors to identify students at risk and pathways for students to seek relief should also be outlined.

The rotation described in this paper is very clinically focused and perhaps does not cater for all learning styles and learning speeds. The recommended working day is 8-10 hours long which does not provide much time for students to complete their own study to back-up principles they have been exposed to during the day’s work.. Some students may still be developing their core knowledge base in the clinical years and may require more time for self-guided study than others.
Trevor Gibbs - (09/06/2016) Panel Member Icon
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This was a well-written and easy to read paper that discussed the duties and qualities of medical students within the clinical environment. It was appropriate to place these qualities under specific headings, which were interesting in themselves. Much of the paper related to a specific school and hence was more of interest to that school than an international audience. The variability of how schools arrange their student activities leaves the paper open to question of its purpose and value to other educationalists
John Dent - (09/06/2016) Panel Member Icon
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The benefits of learning in the clinical environment cannot be over-emphasised. The students described in this paper have the wonderful opportunity of exposure to a wealth of surgical conditions - some apparently presenting as emergencies outwith the normal working day.
However, the paper raises several issues which can negatively affect the benefit of this experience and which require specific action. These have been described under five headings. Broadly though these fall into two categories: educational and practical. Perhaps the paper should be more focussed by being directed to just one of these instead of both.

In order to make the most of the clinical experience described and to facilitate student involvement in the busy clinical environment a variety of approaches are required. In this busy, service-heavy context the onus, understandably, needs to be on the students directing their own learning. I would have liked to hear more about the group’s use of approaches to this, perhaps by structured logbooks, study guides, collaborative learning initiatives and on-site access to additional learning resources. It would be appropriate for the authors to have mentioned the staff development which is required to maximise teaching opportunities (for example giving feedback) in constrained clinical circumstances.

If in another paper the practical problems were to be discussed then this could take the form of creating a practical guide to such topics as student behaviour in clinical contexts, dress and appearance, confidentiality and compliance with local directives on safety and patient welfare. An analysis of the learning environment, for instance the DREEM approach (1) could be used here.
1. Roff S, McAleer S , Harden RM et al. Medical Teacher 19:295-299, 1997.