Remember: You were a student too

Students – can’t live with ’em, can’t live without ’em.

People either love or hate having students. The common catch-cry of those who hate students are the following:

  • These kids don’t know a damn thing about anything, back in my day we knew the protocols forward and backwards!
  • Alternatively: You don’t know the intracellular process for cyanide toxicity? What are you, a fuckin’ idiot?
  • They can’t even do simple tasks like work a stretcher!
  • Are these guys so retarded that they can’t even talk to people?
  • When they come back to station, they want to take a break? They should be studying all day and do patient care all day!
  • Look at this kid reciting all this shit from university, who cares and what does it matter?
  • This kid can’t take criticism!

I want to address these points, because it’s about time that some of the “hazing” that goes on in EMS comes to an end. The environment is changing and we need to stop perpetuating these attitudes now, before we end up hanging ourselves by even further reducing staff numbers. We can’t retain staff in ambulance services today – the workload is too high, the work-life balance is shit, and the job is stressful enough without all the extra nonsense on top. New students and graduates often get the raw end of the stick, at least in my service – you get bounced around, treated like dirt, and constantly reminded that you’re expendable and fully expected to turn around and disappear at some point in the near future. No wonder we all disappear so quickly!

1: You don’t know your protocols like I did

Learning protocols is important, and any student who doesn’t study their protocols needs to be corrected. Protocols exist for a reason – they’re (supposedly) the most clinically beneficial and safest treatment pathway for a syndrome. They’re designed for the lowest common denominator – the most basic of paramedics – so that we’re all on the same page and treating particular conditions the same way. It gives us guidance when we’re faced with complicated problems. Yes, evidenced-based-practice-this and journal-article-that, but at the end of the day your protocols are what protect you and the service.

That said, when a lot of people touting this line started (and it’s usually Diploma-medics), the education system was different. You built up the knowledge over time. Your first year was very basic with only a few protocols to learn – and you added them on as you went along. Students today condense that first year into barely a few months, and then get a few weeks on road to consolidate that knowledge. The curve is steep and practice is limited. Expecting a first year student to know every protocol in the book is ridiculous. Yes, you know it – but you’ve had a lot of time to consolidate that knowledge. I’m willing to bet you weren’t that brilliant on your first shift. If they don’t know it, direct them to learn it and assist in that learning – they might not even be aware of the importance of it, since the university places a significant emphasis on basic concepts and not protocols. They’re learning a profession first and foremost – you learned the service first.

2. You don’t know (x) to the depth that I do

The exchange usually goes like this:

Officer: “So Student, what can you tell me about cyanide poisoning?”
Student: “Well, it affects the ability of the cells to make use of oxygen-”
Officer: “Okay, how?”
Student: “Um, it affects cellular respiration by preventing aerobic metabolism-”
Officer: “Yeah, but how?”
Student: “I’m not 100% sure?”
Officer: “Well your knowledge is shit, you need to go look this up, but allow me to educate you on how it attaches itself to metalloenzymes, inactivating cytochrome a3 and thus cytochrome oxidase…”

By all means, go as deep into pathophysiology as you want – and I encourage you to do so! But this kind of complaint usually comes from people who have no interest in teaching, and every interest in demonstrating their intelligence at every possible opportunity. It makes them look like good mentors, but they’re not – they’re on an ego trip. As a student, it’s important to know what’s clinically relevant first and foremost – the stuff that lets you understand how to do your job. In the above example, the student probably has a functional grasp on cyanide toxicity – they understand one of the critical components. The fact that they don’t know the complicated intracellular process is probably irrelevant, particularly for a student’s level of comprehension.

Mentoring isn’t a chance to demonstrate your intelligence and to belittle students who may not be as gifted as you. If you’re “teaching” by trying to expose as many flaws as possible to demonstrate your knowledge, you’re a bad mentor.

3: They can’t perform common tasks

If I get a first year student, the first thing I say to them is this: “We’re going to look at the equipment that we use the most often, and then we’re going to play with it until you’re comfortable using it. Then we’ll worry about the clinical stuff.” These guys typically don’t get to play with actual, functional ambulance equipment; the university won’t spend the money on it, and what they do buy may not even be in use in that particular service. Even if it is, with the number of students in the degree program, it’s entirely possible your student never even got the opportunity to play with it; hell, they might not have even done it on a real person because of university insurance restrictions!

It’s your job as a mentor to show them the equipment and to teach them how to use it. You got a full introduction to it and were trained extensively by using it – and you continue to use it on a daily basis. They don’t get that chance. Take the time to teach them. Whenever I hear someone complain about this, I ask them if they’ve taken the time to go over it. Sometimes I hear “Oh, I’ve shown them once…” but usually it’s “No, they should know that.” No, they shouldn’t and once isn’t enough. Get them to play with the gear. It’s the only way they’ll learn.

4: They can’t talk to people

To be fair to my colleagues, this is a very valid complaint and one that I frequently voice myself. There are a lot of students (usually first year) who can’t talk to patients properly. But this likely comes from two sources: they don’t really know what questions to ask, and they’ve never been in this setting before, talking to people across a wide range of ages as a figure of authority. They’re going to be a bit awkward, and you have to make allowances for that. Think of the first time you conducted a history – were you perfect? Did you know just what to say? Did it flow beautifully, without any hiccups? Probably not.

Give them a chance to iron it out and make suggestions. They won’t develop that easy banter that qualified paramedics develop until much later – when they become comfortable with their job. They’re focusing both on the patient and the clinical presentation – they’re not going to be easy-going and chatty when they’re concentrating intently. You probably weren’t either. The learning curve is steeper and now they have to cope with talking to people – give them a chance. Some of these guys are fresh from university where they never spoke to adults as equals, or as superiors – remember, we have a sense of authority and command a bit of respect when we turn up. People look to us for guidance and instruction. This may be the first time they’ve ever had to fill those boots. It’s going to take a bit of adjustment.

That said, identify poor communication skills early and target them frequently. Some people don’t have the personality for paramedicine (and no, introverts make awesome paramedics too – the “loud and outgoing” paramedic stereotype is a falsehood).

5: They want to take breaks instead of study

I’m in two minds about this one. Firstly, I make students do patient care all day, every day. Every job is their job. It’s the only way they’ll learn. My station is typically so busy that we rarely get a break, so when we get to spend a bit of time at station, I let my students rest. They’re people too and they need a break. You probably don’t like doing patient care all day either; neither do they. It’s exhausting, particularly when every presentation has a sense of novelty to it. If you have an extended period of downtime, then sure by all means encourage study or practice – but forcing people doesn’t really lead to anything except resentment.

If your student needs work and isn’t putting in the effort, they’re a bad student and should be failed. Trying to force people to learn things ultimately means they won’t learn it for the right reasons, and as soon as that student graduates, they’ll have the exact same attitude. Provide opportunities, provide feedback, make suggestions, but if you try to force people into learning, you’re pushing shit up hill. It’s not worth the effort.

If your student is competent and you’re forcing them to study or do scenarios around the clock, you’re being an arsehole, and I invite you to come work with me so that I can subject you to the same punishment and see if you enjoy it. After all, the fact that you’re qualified means nothing – the field of emergency medicine is ever changing, and you should be keeping up!

6: They’re too focused on theory

Sometimes students are confronting because of how much they know. Some students are like sponges and retain information from journal articles they’ve read in passing about the latest goal-directed sepsis treatment. Sometimes theory is about all they have when they have a lack of practice; they want to demonstrate that they know something and that’s all they’ve really got right now. Alternatively, they know the theory and want to know how that relates to practice, or why practice seems to contradict the theory. And they raise a fair point.

Universities are heavily weighted to theory for two reasons. Firstly, they’re building a generalist degree; one that’s designed to cover paramedicine anywhere in the world, based on current evidence. It isn’t about learning protocols and how to be a paramedic in one particular service, but the general principles of patient management common to all services. Secondly, they can’t get much practical time anyway.

When you get a theory-heavy student, take the time to integrate that theory with practice; they’ll probably make an excellent paramedic if they can build that bridge. You might even learn something from it!

7: They can’t take criticism

How do you give criticism?

Option 1: “Overall that wasn’t too bad, but I think that you were too slow in doing a neuro assessment, and your cannulation technique let you down because you weren’t applying enough traction.”

Option 2: “That was shit, go back and read up on patient assessment for a stroke. Also your cannulation skills are crap, I want to see you practice when you get back to station.”

Option 3: “You did a good job at recognising the signs and symptoms of a stroke and your treatment plan was appropriate. However you were a bit slow with your neuro assessment, and that needs to be a priority in an ALOC patient. We’ll also need to practice your cannulation skills too – you weren’t applying enough traction, which is why the vein rolled. We can work on that though.”

If you give feedback like Option 2, you’re a shit mentor. Yes, your mentors may have yelled at you, but it’s a shit attitude to have. You didn’t like it, so why do it now? You didn’t provide any explanation for what the student did wrong or could have done better – it was just all criticism with no actual instruction.

If you give feedback like Option 1, you do what most people do. This is okay, but the student doesn’t really know what was good about the job either. It’s common for paramedics to not look at what was done well – if we do a good job, nobody comments on it because we were just doing what was expected of us – but for students it’s a different story. They don’t know if they did alright or not – they don’t know what to improve on or how.

Option 3 is generally the best response – it lets the student know what they did well at, while also providing feedback for how to improve. Importantly, it lets them know that you will assist them with improvement. Criticism without the offer of assistance is worthless – your job is to help them learn, not just to provide feedback.

All in all: Don’t be a prick

That’s the bottom line with students. Don’t be a prick. If they don’t know something, help them learn. Provide feedback. Teach through telling stories. Ask them questions. Allow them to rest to process what they’ve learned and to reflect on the day. If you only go looking for things to criticise, you’ll only ever end up with shit students.

Finally, if a student fails, you will shoulder part of that blame in most cases – even if nothing actually happens to you. The first thing they’ll examine is whether or not you actually engaged with them, and if you didn’t, you contributed to that failure. If, in spite of your help, the student still fails, then it’s a problem with them. But if all you do is sit back, criticise, and wonder why they fail, it’s time to take a look at yourself.

We were all students once – but the game has changed. Diploma officers had 3 years of graduated learning along with full time employment to cope with the job – and some of those learned back before IV access, opioids and the numerous other skills were ever introduced and the skill set was much lower. Today, students get 3 years to learn all that plus more, with significantly less time to practice. We have to adapt to the new world.

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