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• That look you get from your chief resident or that “serious” attending.
• The way that “common” people look at you in your white coat.
• That family you just spoke with and explained why their dear Aunt Marie probably won’t live through the night.
• It’s 5 AM and your patient is asleep. “Excuse me, Mr. Jones. Sorry to wake you. I need to just listen to your heart and ask you a few questions and then you can go back to sleep. Have you passed gas or had a bowel movement since I last saw you?”
• Rounds at 8:30 PM. After all, you only came into work at 5:30 AM this morning. No biggie.
• I’m paying $150,000 in tuition for four years (including living expenses) so I can come into work for 12 hours on Saturday. God, I rule.
• You’ve been up for 36 hours on call and you still have a conference to attend in 4 hours. Hey, complaining is a sign of weakness.

Wow, medicine really is serious business.

Popularity: 8% [?]

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

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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

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As I progressed into my third year and especially my fourth, I would often brainstorm creative ways to disappear or otherwise leave rotations early. Here are some of the best strategies and tips for being the “absent” medical student while still achieving a passing grade.

1. Set The Bar Low
   The best thing you can do if you’re shooting for a month-long vacation is to never really make yourself visible that much from day one. Your first few days on a rotation can really set a precedence as to how much your residents expect to have you around. If you spend the first week of the rotation fully visible at all times and then mysteriously disappear, a few red flags will be raised. You do need to “feel out” the rotation to see just how much you can get away with, but don’t sit around the resident’s room in your downtime as this will increase your visibility.
2. Learn The Schedule
   Find out when the attending or your chief resident likes to round, since you’ll likely have to base your disappearances around these times. It may take a few days to learn the schedule, but often the attending will just come out and state that he or she wants to round at a specific time. If you’re taken by surprise, remember you’re just a page away.
3. Build Inconsistency
   Starting early on, you’ll need to build inconsistency with your team. What this means is that they will really never know what to expect out of you. To do this, you’ll want to disappear unannounced for half an hour or so during the first day or two of the rotation. Get lost at completely random times and random intervals, and then miraculously return. As the first week of the rotation progresses, increase the duration of your disappearance. Before you know it, you’ll be gone 2-3 hours at a time and no one will expect anything any different.
4. Study In The Library
   If you like to study in your downtime, always let it be known that you prefer to study in the library for minimal distractions. This gets you away from rotations and you’ll be less likely to be called on for scut. If the residents or attendings object, reinforce the fact that you’ll be available via page and that you are on campus. No argument against you studying in the library can hold much water, so you’ve just got to do it.
5. Map Your Exit Strategy
   Always know your route of escape for each rotation. A good rule of thumb is to never, ever take the elevator on your way out. You’ll inevitably run into an attending or someone that’s going to squeal. Even if you’re on the 11th floor, the stairs are your best friend. Once you’re in the stairwell you are generally home free.
6. Never Carry A Backpack
   Having your backpack on while walking down the hall is a sure-fire sign that you’re leaving. You should always carry just what you need in your white coat. By doing this, you never look like you’re leaving. While you want to create inconsistency with your presence, you’ll want to maintain a consistent appearance. If you plan to study in the library, simply leave everything in your car and then swing by and pick it up.

All Joking Aside

Even though this post is partly in fun, I did actually put these tips to use while on some of my rotations. Obviously, you’re going to have to use some common sense and feel out the residents to see if ducking out for any length of time is feasible. There were certain rotations where I would be absent 3-4 hours out of every day and left early without permission, while others would check up on the students so often that it just wasn’t possible to slip away.

Also, you guys are smart enough to know that if you employ these stealth tactics, you most likely won’t be honoring these rotations. If you get nailed or somebody has a sit-down with you, it’s best just to play the game and ride out the rest of the rotation without being gone too much.

The idea is to achieve the maximum amount of time away from the rotation while still receiving a passing score. In order to do this, sometimes you’ll need to balance a fine line.

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My previous post on needle sticks and exposures was awarded a shiny new post over at SDN. Some questions for me were posed in the discussion, and I wanted to expand on the topic a bit more than simply posting a reply to the thread. Before I go much further, I wanna give bronx43 props for watching my back.

Druggernaught states:

I’m curious how much clinical exposure the guy who runs MedSchoolHell had before he applied to medical school. I’m guessing not nearly enough. Do any of his regular readers know, or is he willing to share that with us here? It doesn’t take long to realize that you’ll be dealing with people who aren’t willing to put in the time for a little common sense preventative care for themselves, who will simultaneously hate you for doing your job and yet demand that you give them the care they need, and that you’re going to have to put yourself at some risk from time to time.

It’s a bit off topic, but looking over that website and some of the posts here, I really wish that medical schools posted some sort of requirements as far as real clinical exposure to avoid the 4.0, 40 MCAT applicant who very quickly realizes he’s made a mistake but is too far in debt and has committed too much time to turn around now.

I had roughly 8 months of volunteer experience, ranging from shadowing in the ER during college to volunteering in private pediatric and family medicine practices in my hometown. This was across three years of college, so roughly 2.5 months out of those college years I was volunteering somewhere. I loaded my volunteer experiences during the last three years of college, and didn’t do much of anything other than school-related stuff during my freshman year. These gigs were the typical “volunteer” positions, so they were probably 1-2 days per week at 3-4 hours each day. Nothing excessive, by a long shot.

I never fully enjoyed any of my volunteer positions. I saw them as a necessary evil in order to boost my chances of getting into medical school. Everybody else was doing it, so I should too. I should have listened to my heart way back then, but I brushed it off as “not liking specialty X.” I thought I’d surely like something in medicine, just not whatever I was volunteering in at the time. Since I didn’t volunteer in every conceivable medical specialty, I rationalized that I would find something that would fit my personality.

The Volunteering Conundrum

The problem with volunteering is that you’re not really going to see what it’s all about short of becoming a full-fledged employee where you actually get to do stuff. You follow some doc around for a few hours and then go home — rinse and repeat while your pre-med mind thinks it’s going to be cool to be like that doc one day. Most volunteer gigs won’t let you do anything remotely close to what you’re going to be doing as a medical student on the wards due to insurance and litigation issues.

What volunteering won’t show you are the long hours, after-hours calls, sleeping in some crappy call room overnight, unruly patients, staying after “office hours” to complete paperwork, aggravated family members, social work involved with “patient care”, and the terrible insurance crisis and low reimbursement to physicians. The only way you’re going to learn about this stuff is to pull a regular job in a clinical setting, and even then experiencing some of these things might be iffy at best. Some of my pre-med buddies were doing stuff like phlebotomy, full-time ER nursing, or even full-time EMTs. Were these people more prepared going into medical school as far as knowing more about what they were getting themselves into? I think that without a doubt they were.

That being said, most students (myself included) have no idea what the practice of medicine is really going to be like prior to medical school matriculation. That’s the nature of the beast, especially when you do the standard volunteer gigs. By the time you get on the wards and decide that it really sucks, you’ve already thrown away two years so you might as well finish it.

That’s what I did, anyway. By the time I decided I really hated medicine, I had already taken and passed Step 1 and thrown away two years worth of tuition and time studying. I still believe this was the best decision for me, as talked about in my post about when to get out of medicine if you’re unhappy. Your mileage will vary, but had I not had student-loan debt incurred during the first two years of medical school, I would’ve probably cut my losses a lot earlier.

UberVolunteer (or Work) More

If I had one piece of advice to give, it would be that you need to really dig down and come as close as possible to finding out what medicine is really going to be like before you waste your energy applying. If this means getting a full-time job working 12-hour shifts doing blood draws, you need to do it. If you can shadow a 1st or 2nd year OB/GYN resident and work every hour that they are at the hospital including calls, that experience will give you a much better idea of what this whole medicine thing is going to be like than pushing patients to their car or bringing down food trays to the emergency room. This isn’t volunteering, this is being an UberVolunteer. I’ll be the first to admit that I didn’t really know what I was getting myself into, but I at least partly chalk that up to the fucked up volunteering system in place. If I had to work 12 hour shifts doing blood draws or follow some poor OB/GYN resident around the hospital while he or she got their asses burned, I would’ve given medicine the finger long before I even matriculated.

Paramediclizard states that I should “learn something from a real physician and student of life.”

Being compassionate, being concerned for your fellow man, doing everything you can to help people—that’s the kind of religion I have, and it’s a comforting religion.

Sorry DeBakey, that stuff just doesn’t float my boat. For me, medicine was just a job prospect. For you, it was a lifestyle and religion. I’m really not that concerned for the welfare of sick people I don’t know. Sorry.

Plus, I like more than 4-5 hours of sleep every night and retirement before my 90th birthday. Hey, that counts for something, right?

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