The following is a guest post by getunconscious. Thanks for the submission!

———————————————————————————————————–

This is just a little something I wrote based on my experiences; I’m at the end of my third year and going into Pathology. I love your blog and just thought you might like it, I wrote it with your theory that medical school is hell in mind.

The Nine Circles of Medical School (read: Hell)

The Circles of Hell
Third Year introduces the medical student to the nine circles of Hell. The circles in third year occur for each individual in no particular order but it is easily determined that some are far worse than others, though they all represent varying degrees of torment and misery for medical students, house officers, and patients alike. Each circle’s house staff are punished in a fashion fitting their personality, and mean-spirited personalities predominate more and more as one descends through the circles. People who were foolish enough to enroll in medical school but realized before it was too late how punishing clinical medicine is end up in Purgatory, this is to say, Pathology and Radiology. Those in Hell are the M.D. graduates who cling to the notion that patient care is a rewarding endeavor.

“Abandon all hope, ye who enter here.”

LIMBO

First Circle: Outpatient Clinic
Here reside the well patients, who need only a brief check-up. Here also reside the not so sick. These patients are ambulatory and one only has to spend 20 minutes to diagnose and treat a simple problem, or follow up on management of one or more chronic conditions. Thus, the medical students are not punished in an active sense, but rather grieve only the occasional walking personality disorder patient. This is the most benign of the 9 circles, and very frequently is even rewarding.

Beyond the first circle, all the others involve overt punishment of the medical student. They may be grouped into 3 categories (similar to Dante’s incontinence, violence and fraud). The first involves basic care of the inpatient and is the least punishing. The second involves care of the very ill, and the third and lowest level of hell involves active interventions that require one to scrub in.

UPPER HELL

Second Circle: Psychiatric Hospital
The psychiatric hospital represents the most benign form of inpatient rotation. Though students may be occasionally screamed at by the mentally ill, there is usually no physical exam required and rounds move quickly. A good assessment and plan is something like, “Assessment: patient still crazy. Plan: go up on the anti-psychotic du jour.” Psych attendings are rarely if ever mean and tend to have entertaining and wacky personalities. Best of all, one can be done for the day in less than 6 hours.

Third Circle: Consult Service
The consult service is usually a subspecialty like infectious disease, cardiology, rheumatology, neurology, etc. This is the highest level of hell that involves being in a regular hospital. While consult services are plagued by a relatively unpredictable schedule (primary teams can call whenever), they are not burdened with overall responsibility for the patient. They deal only in one specific area, and while they may follow up, they do not take call and often do not accept consults after 5 pm. As they are almost always a specialty service, they do not have to deal directly with management of the patient’s comorbidities, a definite added advantage.

Fourth Circle: Pediatric Floor
In the fourth circle, one is part of the “primary team,” meaning that this team bears the ultimate responsibility for the patient and must deal with the patient’s multiple problems. In pediatrics, the patients frequently only have one diagnosis, which is an acute diagnosis, and little past medical history. In addition, the attendings and house staff are considerably nicer than those on medicine. The patients, being mostly cute little kids, are intrinsically more likeable. For these reasons, if one must be on a primary team and suffer the scourge of overnight call, pediatric floor is the least punishing.

Fifth Circle: Medical Floor
In theory, this is the same as pediatric floor, only for adults. However, there are several reasons why the medical floor is a lower level of hell. The patients often have many, many medical problems that must all be managed in concert. The history and physical is thus quite a burdensome endeavor and includes a significant amount of past medical history. In addition, the patients themselves may be combative and non-compliant. Not infrequently they are demented and cannot give a good history. While pediatric patients may not be able to give a history, the parent can give a very detailed history in 90% of cases. In addition to the patients, the culture of internal medicine is not near as friendly and welcoming as that of pediatrics. Though medicine attendings may not be overtly mean and yelling at people, they often have a giant stick up the butt and are never satisfied with anyone’s presentations or fund of knowledge. Add to this the 4 hours of rounding each day and it is self-evident that medicine floor is truly the 5th circle of hell.

MIDDLE HELL

Sixth Circle: Emergency Room
In the emergency room, one is constantly assaulted by an unending barrage of patients, ranging from the scarily critically ill to the very frustrating patient who just wants to ask for Vicodin or has a cold and didn’t feel like waiting until the next day to be seen by primary care. Thus, one is condemned to feeling either panicked or irritated 100% of the time. With ER patients, there is no winning. In addition, ER nurses are famously mean to everyone, not just students, but residents and attendings as well. Then there are the services to which ER tries to admit patients. When ER calls a service to admit a patient to their floor, the intern on call WILL be pissed, no matter how legitimate the admission. ER house staff have to burn off this frustration somehow, and will often take it out on the defenseless medical student.

Seventh Circle: Intensive Care Unit
The intensive care unit houses the sickest patients in the hospital, and many will expire here. In order to even be admitted to an ICU one has to be more or less trying to die. Thus the first thing that you will notice upon entering the ICU is an eerie stillness. Patients are all obtunded and hooked up to many, many machines and tubes. Here the medical student will often rapidly spiral into depression. Withdrawal of care occurs on a regular basis. When the ICU is not depressing, it is anxiety provoking, as patients code on a daily basis here. The ICU is the lowest level of hell that does not involve the torture of scrubbing in.

LOWER HELL

Eighth Circle: Operating Room
The operating room punishes the medical student in a very ritualistic, unforgiving fashion. First, the student engages in a ritual reminiscent of Lady MacBeth—scrubbing in. This involves rubbing each side of each finger 10-15 times with harsh iodine soap. One must wash in a precise fashion from distal to proximal and rinse in the same fashion. Then entering the OR without touching anything the towel is used to dry the hands in a similar regimented way (careful! The air above your shoulders is “contaminated” so don’t put your hands up too high!). Afterwards, the gown and gloves are donned and the student is hereafter confined in his own little prison, unable to touch anything except the operating table. Once (s)he is standing in the proper location (usually one where the operation is difficult or impossible to see), the student must remain motionless for the duration of the operation, often more than 4 hours. In some cases the student may have to retract this whole time. Thus the main form of punishment in this level of hell is immobility and inability to eat, drink, pee, or itch. One often sees only through a fog, as splash guarded masks are employed to add to the punishment, despite the fact that in non-trauma cases there is virtually no risk of any splash. The student is usually interrogated at some point by the attending and/or house staff on medical facts, most commonly anatomy, but this is a much less severe form of punishment than the complete imprisonment of being scrubbed in.

Ninth Circle: Labor

Popularity: 11% [?]

The following is contributed by Half M.D., the author of www.halfmd.com

The two things that piss me off quicker than anything else are inefficiency and ignorance. So far, the people who run my family medicine rotation have shown both. I’ve had one setback after another in the months leading up to this clerkship. Back in January, I wrote the course director to tell him that I would be going out of town for a special conference during his rotation. He never wrote back.

So I wrote the co-director of the course and told her the same thing. She never wrote back.

Then I wrote to the secretary for this clerkship. It turns out that she had been fired and replaced. I then wrote the new secretary of the clerkship. She never wrote back.

I went to the third year coordinator for my university to ask what was going on. I should have known something was wrong when she suggested that I make a physical appearance to the family medicine office. At that time, I couldn’t figure out why no one in the department could reply to my e-mails.

I then tried calling… multiple times.

I finally got through and confirmed all the information I provided in my original e-mail. Heeding the advice of the third year coordinator, I went to the family medicine office last week to make sure that everything was intact for my clerkship. You can imagine my surprise when I discovered that the secretary denied having ever received any information from me about my absences or where I wanted to practice family med. I had saved the e-mails and pleaded, “Here’s all the information right here.” To which she replied, “You should have e-mailed me more than one time.”

Through talking to the secretary of the course coordinator, I had hoped that everything would have been figured out for this week when I finally started the clerkship. I was given the wrong phone number to my preceptor’s office. And then when I finally managed to get through to his nurse, I was given the wrong location of his office.

I showed up bright and early Monday morning ready to see patients, but found out that he had a second practice located across town. I tried calling him at his other office multiple times that morning until I finally reached him at 10:00a.m. Keep in mind that he was supposed to have arrived by 8:30. I had to drive like a madman across town to this other office just so that I could be two hours late to my first day of my clerkship.

If things continue like this for the next month, I think I’m going to punch someone before it’s all over. Today is Wednesday.

Just in case any attendings are reading this, if you ever happen to be in a position to lead medical students—especially as a clerkship director—make sure that you have a good support staff and that everything in your clerkship is well organized. There should be no reason why students are given the incorrect telephone number and address of their clerkship location. We are paying for that education after all.

Popularity: 11% [?]

First I’d like to give a shout out, if you will, to this website and its creator(s). A fascinating concept and an equally fascinating read. No doubt.

Next, I’d like to state in clear and unfortunate terms that I am a recent medical school graduate. I state that so you’ll take me seriously, as I plan to offer several insights about the profession in the coming paragraphs. I’ll also state that I’m not a D.O. or an international medical graduate, thus increasing my status, if you will, even more in your minds. Really though, no offense to my osteopathic colleagues and immigrant/temporary emigrant physicians/physicians-in-training.

I’d like to start out in existential mode, if you’ll allow me. *Squints eyes and rubs chin*. Why would anyone in their right mind choose to apply to, or for that matter, attend medical school? Ah! You’re taking on the pensive pose too now, aren’t you?

Brief and simple answers first come to mind. Money. Status. Ego. Race. Ethnicity. Those were too easy to come up with. I’ll expound on those very shortly, but let’s brainstorm, as my KG teacher used to say, and think of a few more. Ah yes, it’s coming to me now. Retardedness. Delusion. Lack of common sense. Boredom. My parents told me to. My parents did not tell me to, but I know they would have if I didn’t. I pretend like my family did not influence my decisions, but in reality (and don’t tell anyone), I’m a complete slave and bitch and indeed they are the reason why I am an aspiring physician.

Okay good, now we’re getting somewhere. We’ve laid the groundwork to incredibly profound thoughts which are yet to come.

I have to go eat dinner now, so as they did in 1980s sit-coms, I’ll make this a to-be-continued. Rest assured that I will be back for several follow-up visits (no put intended.. medical and medical-related jargon is not my cup of tea and frankly bores the shit out of me). Let me rephrase.. I will be with you in my usual brilliant form in the coming days. And to those of you starting to get pissy, I say pipe down, take a step back, and re-evaluate your existence. What do you really have? A kick-ass histology text? Superior ABG obtaining technique? A stethoscope with a hip pediatric chest piece? Sweet pics from your “white coat ceremony” which you subsequently uploaded on Friendster? Wait, did the AMA hook it up with a free Netter’s? Man that is lame. I suggest you take a seat and listen to what I have to say…

Related Link: Mesothelioma Video

Popularity: 9% [?]

www.wikipedia.org: Rather than a generic focus of education, Nurse Practitioners are able to specialize in an area of study they desire (e.g. Pediatrics, Family Practice, Adult, Geriatric, etc.), and provide care within the scope of their expertise. As well, Nurse practitioners in certain states can be “psychiatric clinicians” and perform similar practice (though at a different level) as a psychiatrist would.

Salary.com: Nurse Practitioner salary (25th-75th percentile) is $67,166 - $78,497. Generalist physician salary (25th-75th%) is $115,260 - $152,715.

Wikipedia: According to numerous salary reports throughout the years, CRNAs remain the highest compensated of all nursing specialties. Their average reported annual salary range in 2006, reported by the AMGA Medical Group Compensation and Financial Survey, was $140,396. The mean annual salary for an anesthesiologist in the United States in 2006 was $184,340. [1]

What’s my point? Fair question. First, NP’s have the same scope of practice as any physician. This is clear from my first statement about NP’s specializing. Whatever specialty you want as a physician, there’s an NP that can do the same thing. “But surely not for surgery?!” is the cry of retort. Well I promise you that within the next 10 years, some politician is going to realize that “Hey! PA’s and Surgical Tech’s can pop out gallbladders just as well as a surgeon can!”

Also note the salary differences. Now I can’t find information regarding the various NP specialties, but compare the lowest specialty to the most basic NP, the salaries are comparable, and the highest NP position to the highest (according to MSN.com) paid physician. When you do, you’ll note that physicians do, in fact, win. And NP’s must do 2 years of post bachelors work and one year of work experience (for a total of 3 years) compared to the 4 years post-undergrad for a physician. Big whoop. One year.

Well please note, the average med student graduates with around $200K in debt, while, according to Barry.edu (a school in FL that has both NP and PA programs) the PA program (the more expensive of the two) is $24,810.00 per year. This is roughly equivalent to medical school. However, you’re paying twice as much in med school because you go to school for twice as long. Also, one of the 3 requisite years for NP school is clinical experience. This is a paid job. RN’s make (again, 25th-75th%) $49,479 - $59,114. That means that if a med student and an NP were compared at the same time, 4 years post undergrad, the med student would be out $200,000 (roughly) and the NP would be out $521 (rounding to $25K/yr for both programs, and using the 25th percentile for RN’s). Add the interest on a med school loan, and that puts you at about $600,000 paid back (bc you pay back about 3x what you borrow, esp the financial geniuses that make up our MD population).

Now lets say that no matter what you do, you make $30,000/year more than your equivalent NP. You figure that after 30 years of practice (putting you at the nice comfortable retirement age of 66 for those of us that took the direct route) and you’re up $900K. Worth it, right? Well we haven’t incorporated malpractice insurance. Have you ever heard of anyone suing their NP? I sure as shit haven’t. Factor in 30 years of malpractice insurance bills, and I’ll promise you it brings you right back to even (not to mention that physicians’ salaries are trending down relative to inflation while all nursing salaries are trending up). Couple that with the hours worked by an NP relative to an M.D. and the paperwork/legal hassles handled by an MD that aren’t worried about by NP’s, and the conclusion is obvious.

Do the same thing for the same amount of money, and have a better quality of life. Become an NP.

Popularity: 14% [?]

The following guest contribution was written by Locus Potus, who writes for the blog Hybrid Vigor.

Dear Friend/Family/Colleague:

You are receiving this letter because someone you know is about to apply to medical school. The entire lengthy process is riddled with intricacies, misperceptions, variables, and unknowns that make it unlikely you realize the full extent of what this person is about to do. I’m sure that you will try to empathize over the next year, but some things in life must be lived to be understood. Even my own knowledge base, seasoned over a long application cycle and qualified enough to enter medical school this fall has already become outdated with changes to the MCAT and the application process. Nonetheless, I will try to inform you as best I can.

A pre-medical student is born the instant they make the decision to apply to medical school. For most, this happens years before they ever start filling out application forms and taking tests. Making good grades is an obvious undertaking, but they must also be significantly involved in extracurricular activities, all while befriending busy professors to write raving letters of recommendation. All this extra work makes them an “average” applicant. Thus, for the pre-med you know, the application process began long ago.

The initial step in applying to medical school is the Medical College Admissions Test (MCAT, pronounced “em-cat”, not “em-cats”). For most people, this test is prepared for months beforehand, often utilizing expensive test-prep classes (>$1000), and on top of a full work/school/life load. Like most standardized tests that can be studied for, it does little to measure actual intelligence, but does reflect baseline knowledge in the sciences and reading comprehension needed for medical school, particularly in the first year. There is a weak correlation between MCAT score and USMLE scores (the licensing exam for MD’s) and even less predictability with being a good doctor. The full details of this 8-hour monstrosity could fill pages, but suffice it to say that the test itself is needlessly long (one quarter of the test, the writing portion, is generally not considered by medical schools), expensive (>$250), and just another “weed out” step in narrowing down the applicant pool into only the most studious and determined applicants. In my day, the exam was only held twice a year, leading to a great amount of anxiety on test day, but thankfully it is now being offered multiple times per annum.

Assuming your acquaintance has made it this far in the process and taken the test, next up comes the actual application mediated through the American Medical College Application Service (AMCAS) beginning in June, the year before they are to start med school. This is the pre-med’s first official foray into the needless bureaucracy that is the American medical system and a continuation of the expensive journey into medical school. All coursework and activities must be meticulously detailed in the AMCAS application. As this information will be sent to schools in a standardized format, pre-meds will strive to polish their resumes as best they can. More importantly, however, the AMCAS also collects a personal statement, also known as the application essay, which asks the question “why are you interested in medicine.” Herein lies one of the greatest challenges facing any aspiring physician – to put into words a lifetime of experiences that led them to pursue their career path. The personal statement can make or break an application, especially for the “average” applicant since there are thousands of others who likely have the same exceptional grades and activities. Using the cliche “I’ve always wanted to be a doctor since my parents bought me a Playskool doctor set” might as well be asking for a rejection because the admissions committee sees hundreds of these essays every year. No, this essay must be special. It must reflect who they are as a person. It must grab the reader’s attention and compel them to offer the writer an interview. Not surprisingly, finding a unique way to say “I want to help people” can be difficult. It will take a long time to write, with multiple revisions and criticisms. If your applicant is on the ball, it will be completed before AMCAS even begins to accept applications in June. Whatever you do, don’t question why they are spending so much time/stressing on an application because this step weighs heavily on the rest of their careers and lives. Applying early is a crucial advantage in a cutthroat process, where any edge should be employed.

Before hitting the Submit button on their internet browser, pre-meds must select their list of medical schools. Unlike college, where everywhere basically teaches the same material in the same way, each medical school has a distinct personality and should really only be chosen after some consideration. US News and World Report rankings is not the best of guides, as they are based mostly on revenue from research grants, not necessarily educational practice. Different schools will appeal to different applicants based on their interests. It is difficult to say one school is “better” than another, especially given that all Allopathic medical schools require national certification. In this regard, there are only varying degrees of good.

Although your pre-med may be very smart and accomplished, applying to the very top schools is not always a wise investment. Most applicants to every school will come from the top of their classes nationwide. No, Harvard will not accept them just because everyone says, “she’d make such a great doctor and she’s SOOO smart!” Even a 4.0 GPA and a high MCAT score is no guarantee to any medical school, many such applicants find themselves applying again in the next year (especially if their personalities are unappealing during the interview). The list of schools must also be chosen prudently because each additional school costs $30. I applied to an average number of schools, fifteen, which cost me approximately $500. In return for this exorbitant fee, which you must pay, AMCAS will check your transcript for accuracy (that applicants enter themselves) and send all the information in a nice, neat electronic file to each medical school. That’s right, for about an hour’s worth of work on their part and minimal production time/cost, they take what most student’s can save over an entire summer - but I digress and this fee pales in comparison to the next step in the application process. Did I mention that AMCAS processing takes about a month (if you’re early)? If your pre-med’s spirit and bank accounts are not exhausted by now, they soon will be.

Once AMCAS finishes their part, medical schools will begin collecting the primary applications and processing them in what amounts to another month of waiting. Mind you, each school will do things differently (see above about researching schools), but most will be willing to offer you their own, secondary application, for an additional fee of course. For each school selected in the AMCAS, pre-meds can expect to pay anywhere between $50-$120 for the pleasure of writing additional essays on exciting topics like “Why do you want to be a physician?(yes, they ask it again and heaven forbid you put the same answer as your primary application)”, “What makes you special?” or “Why do you want to come to School X?”. If they’re lucky, they’ll be able to recycle essays between schools, but expect lots of long nights and stress while they come up with answers that must not only be well-written, but sound original and fresh. If they applied to 15 schools like I did, it becomes very time consuming and expensive for this step alone (~$2000).

In another long pause after the frenzy to return secondary applications – remember, early is better – pre-meds will try to recover some lost money and time. Soon, interview season will be upon them. Don’t expect any particular reason why or when school’s schedule interviews. As I mentioned before, even excellent applicants don’t get interviews everywhere. An application may sit at a school from July to January the next year, presumed as a rejection, only to be called up for an interview. The logic behind each medical school’s admissions decision to interview (and accept) is a well-guarded secret. If you haven’t noticed odd behavior already, your pre-med will likely to obsessively check their email accounts every couple of hours/minutes for any word from schools. Small letters in the mail are generally rejection letters, get used to the sight of them arriving even if they’re a “better-than average” applicant. (Note: sometimes schools will offer interviews via snail-mail, but they will usually accompany an email).

A brief commentary on chances of admission: It is important for you to remain realistic during the application process. Making it any step beyond the secondary application is an achievement. A few exceptional students will be very fortunate in the process and garner numerous invitations and eventual acceptances. This is not the norm. Almost half of all applicants nationally will not be accepted anywhere and more applicants are applying every year. Many applicants get only a few, if any, interview invitations. At any medical school, expect only 1 in 5 applications on average to get an interview. Of these, only 1 in 3 or 4 will be accepted, for an overall acceptance rate between 3-10%. It may be tempting to stop worrying after receiving interview invitations, its not over until you see an acceptance letter in hand. In each of the waiting periods, be patient and supportive, but don’t assume that an acceptance is coming, chances are against them.

Assuming your pre-med is lucky enough to get an interview invitation so begins another round of expensive and time consuming preparation. Interviews are usually done on the pre-med’s own (you stay at home) and in proper business attire (more $$$). The cost of tickets and hotel can cost hundreds per trip. In these nerve-wracking situations, they can be expected to answer questions like “Why do you want to be a doctor (yes, they ask it again)” or “Tell me about yourself.” Unfortunately, there is a high degree of variability in interviews – some interviewers are nice, while others can put on a full-out grilling session, even at the same school. This is another reason why applying is often called a “crapshoot.” Applicants must prepare themselves to answer questions about medicine in general and also weaknesses in their application without sounded too rehearsed, although they are likely to have answered the same questions everywhere they interviewed. The day can be long or short, depending on the school, but almost always awkward formal – it’s a face to face meeting with the competition. However, they can be fun as pre-meds are usually Type A personalities with interesting backgrounds or else they wouldn’t have made it this far. Interviews are generally extended from September to February, don’t read too much into the timing.

Some schools will start accepting students soon after they start interviewing and are known as “rolling admissions schools.” Others, like many of the top schools, will make their applicants wait until March 15th to hear if they are accepted, waitlisted, or rejected, known as “non-rolling admissions.” Some schools will not even send any kind of notification at all, leaving many pre-meds to wonder indefinitely. In perhaps the worst kind of torture this process can put you through, a pre-med can be put on the waiting list of the school they want to attend and held in limbo until the first day of school. At any given moment, even well into next July or August and after plans have been made to attend another school, a student may be accepted off the waitlist. Therefore, a pre-med applicant may never really know where they are going to school up until the day they actually attend somewhere – often over a year after they initially submitted their primary AMCAS application. Don’t expect definitive answers from your pre-med since there are many things to consider like cost (including financial aid with its own application process), location, and teaching style. I hope at this point you are beginning to understand my initial statement above regarding the complexity and strain involved in the application process.

If your pre-med does get accepted to medical school – any medical school – they are to be thoroughly congratulated. They beat the odds and the thousands of people clawing for a spot. A common trend these days is for applicants to take a few years off before school to add another dimension to their application. I highly recommend this approach for students because it gives them a chance to live life and get a break from school before the onslaught of med school itself.

After all this expense, effort, and drama, the “pre-med student” evolves into a “med-student.” Keep in mind that most pre-meds and med-students have a marginal knowledge of actual medicine. Even after medical school, we’re not very qualified to practice medicine on our own until after years of residency. So, hold off on your impulse to start asking questions about that burning sensation you’ve been meaning to see a real doctor about. Also keep in mind that the progression to medical student and eventual doctor is not a guarantee of financial success. Medicine is not what it used to be. The bureaucracy and hoops to jump through only continue during a physician’s career, which is probably why they make us do it when we enter the profession – they want to see if we are willing to put up with it. Many doctors will graduate with six-figure debts, live modestly, and lead stressful lives well into their 30’s and 40’s - something to consider before advocating a hand in marriage to any future doctor. Many experts agree that our healthcare system is in disrepair. Due to absurd insurance rates and frivolous lawsuits, physicians are leaving their practices in droves, resulting in a deepening healthcare crisis. Physician’s wages are determined by a pencil pusher at an HMO and may decrease with a change in US policy. Despite this bleak market outlook, pre-meds will still strive at great lengths to enter into medical school.

My strongest advice is to not assume too many things and to be patient with your pre-med during the application process. Ask questions and be prepared for uncertain answers. They will need your support through it all and even beyond. The stresses of becoming a doctor are great. Medical students have some of the highest depression rates among any profession. After all the drudgery, conformity, and expense, the original, bright-eyed, and optimistic person you know may be gone. I can only hope that I don’t go that way myself.

This letter is by no means comprehensive and maybe a little dated, but I doubt that much as changed in a year. I hope it serves as a primer for one of the most difficult years of anyone’s life – many people would agree that the hardest part about medical school is getting in. As a further resource, I recommend the Student Doctor Network forums as a place to ask for more information. Many applicants, including myself, have relied on this site while applying, especially when most of the people around me didn’t fully understand what was going on.

Good luck to you and your pre-med.

Sincerely,

Locus Potus
Nom de plum

Popularity: 11% [?]