Medicine Is Serious Business
- 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.
The Nine Circles of Medical School
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
The Hospital Dress Code Is A Joke
I remember my first day on inpatient rotations. I woke up, showered, and then put on dress slacks, a dress shirt and tie. After looking in the mirror, I knew I was dressed more appropriately for a business sales presentation than bouncing around on the wards.
Even though it didn’t feel right, I did it anyway. Students, residents, and attending physicians dress up for the wards because it’s been done since the beginning formalized patient care.
Just because everybody does it doesn’t mean it’s the most practical thing to do. Do patients really care what their physician wears when they come to see them on rounds? Without a doubt, some do.
Does this mean that you should cater to your patients’ expectations 100% of the time? Hell no.
Business attire is not practical for the hospital inpatient setting, bottom line.
Let’s consider an inpatient medicine rotation. Many procedures are done on a daily basis, which often result in some type of bodily fluid coming into contact with your freshly-pressed dress shirt. You’re on your feet most of the day, and a comfortable pair of tennis shoes or Crocs makes more sense than dress shoes. Neckties harbor bacteria — they are not necessary.
Inpatient ward medicine is suited for scrubs, and not only while on-call. Wearing business attire and changing into something more appropriate each time you need to do a procedure is tedious and unnecessary. Although business attire presents an aura of professionalism to the patient, physicians need to start thinking more about practicality and less about what other people think of what they have on.
My Vascular Surgery Attending
I lied. I told you in this post that the next installment at MSH would be about alternative career paths. Well, it’s not.
As most of you already know, I hate surgery. Now, vascular surgery is the evil mother from which the rest of surgery is born. She’ll rise up and bitch-slap you right across the mouth just for looking the wrong way.
My first surgery experience was actually in vascular surgery. I showed up at 6:00 am to the offices where the residents hung out for the 5 minutes each day that they had free. They had already been there for some time, as evidenced by backpacks and extra shoes strewn about the room. Just like all other first days on new rotations, I was clueless as to what to do or where to go.
I made my way to where I thought the vascular surgery patients stayed in the hospital, and after asking several nurses I finally found the residents working.
Medical School In a Nutshell
You busted your nuts to get to medical school, studying your ass off for four years to keep your GPA up and to ace the MCAT. Once you’re finally there, medical school can be summed up rather nicely.
Year 1 is simply memorize and regurgitate. Commit random facts to memory and spit them back out on some stupid test. Rinse and repeat. Hanging out and drinking after exams is a frequent occurrence.
Year 2 is more memorization and regurgitation. Commit more random facts to memory and take more silly tests. Drinking at bars after exams is still somewhat common.