Quit medicine? (part one)

When I was a medical student there was a girl who, after 2 years of medical school, decided…she didn’t want to be a doctor after all! I remember hearing a rumor that she decided she would rather spend her days swimming with dolphins. Then…she was gone.

That got me thinking, for the first time in my life actually, what do I WANT to do? Prior to this, my standard reply of “I want to be a doctor” achieved sufficient accolades from everyone, and the satisfied look on their faces served as confirmation that I was on the “right path.” I never really gave it a second thought. But this girl…had the audacity to decide on her own that she was going to “throw away” everything she’d worked for (and all the sacrifices her family had made to allow her to opportunity to attend medical school) and make the “irresponsible” choice to swim with dolphins in lieu of becoming a doctor. I mean, who does that?

At that time, I thought to myself: good for her for knowing what she wants to do, but why not finish medical school first, *then* go swim with dolphins? That way, if her perception of a dolphin-swimmer’s life was misaligned with the reality, she would have “being a doctor” as a back-up career option.

So I spent no further time pondering any other choice at this time. Instead of thinking about what I *wanted* to do, I focused on completing the path I was on, because that’s what made sense to me. I reminded myself that the most difficult (academic) work was complete after taking the USMLE Step I (after 2^nd year). The third and fourth years were the clinical (interesting, “field-trip”) years, where you *finally* get to legitimately “play doctor” for real! Why quit now?

But *when* IS a good time to quit? Once you get on the ‘medical-training-in-America’ highway, there is no “easy” time to deviate. It makes sense to complete medical school because once you achieve your advanced degree, you can *still* go fold jeans at The Gap if you want. Nothing (but a few years) is lost by finishing the degree program. So you finish…

Then, you can’t quit before internship. You can’t even get a medical license without completion of an internship! It only makes sense to obtain licensure. Why go through all of that training (and torture) in medical school to become a doctor, and then take away your ability to actually get a medical license because you’re too “lazy” to do just one more year?

Unless you know something that I don’t (which is quite possible), there’s nothing you can practically do as a new doctor (with no other training) without residency completion. You can’t really make any money (and with the huge burden of student loans, *choosing* to NOT make money is a crazy option), aren’t respected as a doctor, and are ostracized completely from “real” specialists (and everybody’s a specialist these days). Who wants to sign up for that? When in just 2 more “short” years, you too can be a board eligible specialist! So…I made up my mind that I would complete the entire training program, and *then* I could reevaluate my decision from a position of “safety” – as a board certified physician specialist.

As a 4^th year student contemplating specialty choices, I decided *then* that (despite everything I thought I knew about myself) I had no desire to spend significant time taking care of sick people – gasp! And this realization just kind of snuck up on me as a senior medical student.

Before medical school I thought I wanted to be the quintessential doctor who took care of the entire family their entire lives, family medicine. Then I realized that people are “difficult” and I do not want to be ‘responsible’ for people, sick people…and certainly not their entire lives! Whose crazy idea was that in my head all those years, thinking I could pull that off?

So I eliminated the kids and pregnant women which is essentially internal medicine. That felt better. But still, too big. Too much. Too long. But, nothing else was particularly appealing, and this late in the game many options are essentially removed from the table. So IM it was. But then, I signed up to do an anesthesiology rotation because I’d heard it was super easy…and after 3.75 years of medical school, I was so ready for easy!

True to its reputation, the rotation was a cake walk! Show up at 6am (which was the most difficult part) and intubate a patient or two, then go “read” (i.e. do whatever) until the next morning. There was the opportunity to see trauma anesthesia, which allowed the student to do a-lines, venous lines, and more! Very cool stuff! Still not completely sold on my IM choice, I switched to anesthesia, just like that. I was desperate to “find” my “place.” I was a gypsy, and even as 2nd semester 4^th year (senior) student, I was uncommitted!

So I clung to anesthesiology. Sure, I was cognitively aware that I would not be able to intubate and leave. I realized that the days began very early, and were long. Call was busy, and the training stressful. But, I *also* didn’t have to take care of a bunch of people…forever. One patient at a time. Done with surgery/procedure, done with patient. Sounds perfect.

Let me say, it is about this time I began to awaken from the unconsciousness of whirlwind academic overachievement and hierarchal indentured servitude, and realize that “maybe this whole doctor bit is overrated by those *stuck* IN it.” As a coping mechanism, I think many doctors just don’t *think* about their lives, and are unable to consider alternative life paths because they subsist on the delusion that this way is the only way to “be somebody.” And it doesn’t help that doctors typically see themselves as professional corporations and not the workers that they are, so their work conditions are super shitty, but no one cares. Especially not the doctors.

But I digress.

As an internal medicine intern (required prior to starting my anesthesia training) I actually had a great time. Becoming an intern is, in many ways, the prize for years of hard work and being invisible. Years of proclaiming “I’m going to be a doctor on day” to finally *being* a doctor is a huge step forward. Because, honestly, how many of us know someone who’s “going to be a doctor one day?” Not a big deal.

Just *finally* being the DOCTOR was enough positive momentum to sustain me through the internship year. And the amount of practical knowledge I acquired was worth the “abuse” and “sleep deprivation” at that time in my life. I felt legitimate (although incompetent). Also helpful was the knowledge that I was moving on to ‘bigger and better things’ with anesthesia. I was NOT going to be “doing this” (rounds, carrying a pager, writing long H&Ps, the whole deal) much longer. I was going to do short notes, cool procedures, and sit on my ass all day as an anesthesiologist listening to uplifting music, reading trash magazines, and getting paid well. Couldn’t wait!

So you can imagine my disillusionment when I actually began the anesthesiology residency. It was early mornings and long days. It was being on-call and lack up sleep. It was lonely. And in some respects, demeaning, boring, yet stressful all at the same time. And, the worst part was (for me) – there was no one to talk to, and minimal patient interaction. Who knew that taking care of sleep people would be lonely and impersonal?

Clearly, I hadn’t thought out my specialty choice well.

What now? I don’t want long term relationships taking care of sick patients. I don’t particularly like small children (even more so before I had my own). Being all up in vaginas all day was the *last* thing I found appealing. What else is there? Maybe I would go back and finish IM, and then subspecialize? But that would tack on like 5+ years to my training, and after this whole fiasco, I had no time for such nonsense. After all, I’d been trying to find an exit off this medical highway since 2^nd year medical school, but stayed on for very logical and practical reasons. But at some point, I just had to draw the line.

It is important to keep in mind that doctors have done themselves a huge disservice by subscribing to the current status quo of medical training. Unlike nurses, or PAs, we cannot just “switch” specialties and “do a new thing” when we get bored with the current thing, or otherwise we can no longer do certain procedures or function in certain capacities. Nor can you move to another part of the country on a whim and expect be granted a medical license from another state (never mind the fact that you already HAVE a medical license after passing a *national* exam, which is asinine and a post for a different day). For multiple reasons it is not practical for a mid-career physician to “go back” and do another residency to obtain different credentials to do a new thing. Overall, medical education does not easily extrapolate into meaningful work outside of medicine. So, once you choose a specialty, you’re essentially stuck! A decision you make about your career at age 25 had better serve you well when you’re 50.

Oh, the pressure!

After all of this, I decided to pursue emergency medicine, primarily because it allows doctors to be doctors when they want to be doctors – and cool doctors at that. But, when you didn’t WANT to be a doctor, you could do something else. Anything else! And still be cool. With a solid “back-up” plan that is EM. And the cherry on top of that sundae was: I didn’t have to take care of sick patients for forever. I can step in when they really NEED help, I can TALK to them, I won’t be lonely, I get to do cool stuff….and then…I get to go home! To my life. All the while, making 100% more than a pediatrician, and 50% more than FM with less stress, less work, less ‘distraction’ from my REAL (non-doctor) life. (And judge if you must, but money *does* matter, especially when the cost of medical education is in the hundreds of thousands of dollars!)

Fabulous.

Right? It’s all good now as an ER doctor….isn’t it?

Medical Memoir - In Stitches One Girl's Opinion

Medical school memories came *flooding* back as I read Anthony Youn’s memoir, In Stitches.

Medical school was a time in my life where the details are sketchy because it was a blur of studying, isolation, anxiety, frustration…sprinkled with intermittent moments of fascination and joy. I can completely relate to his thoughts about pediatrics, “Little people, little dollah”, and being torn between life-style specialties and being a “real” doctor. I shared his dislike for the standardized patients and the weirdness that entire situation evokes in all of us.

My favorite aspect about this book is its honesty and authenticity. As I devoured the book chapter by chapter, I felt like I UNDERSTOOD Tony. I was able to peek into a life very similar, but very different from my own. His book was truthful, the language was clear, the humor and candidness kept me interested and I really felt like I traveled this journey with Tony. As I read the pages, I thought of my OWN similar experiences….and my reaction to them. And as I flipped the page….reading his words were like reading my own mind. It was quite amazing!

There were only two questions that stayed with me through-out the book: Why didn’t his family help him acquire better living conditions? And was he really a virgin until medical school? (implied, but not stated)

I will say that I feel like the first part of the book would appeal more to young men, with all the talk about girls, women, and overall “manning up.” Since women do not (typically) go through this, it’s all very foreign in an annoying kind of way (as a woman). I was much more interested in…all the rest. Thankfully there’s plenty of ‘all the rest’ and the book was thoroughly enjoyable.

I would LOVE to read a “part II” plastic surgery residency memoir. It really was *that* good!

Attendings who don't want to teach

Q: Now that I'm *officially* well into my intern year, I realize that some of our EM attendings are not interested in teaching (or otherwise interacting) with interns. As an intern, I'm offended. Is this acceptable behavior, and how should I handle it?

A: You're right, the attendings should be willing to work with ALL of their OWN residents (interns included). Its one thing to shun rotating residents/intern/students, but *your own* should be taken care of.

There are two different ways to look at this to help explain why SOME (i.e. not me, LOL) attendings avoid students/interns. The first way is to try and see their point of view.

Imagine you’re an attending:

When you go to work, you feel exposed (legally) because the residents are a liability. They don’t always know what to look for, what to tell you about, and how to treat the problem. Even if you, yourself, get up and go see/talk to the patient, you may miss something in your short interaction. And there are LOTS of patients. Actually, you feel overwhelmed at times because you’re responsible for the actions of others, although you don’t know what they’re doing/hearing/seeing. You have to ‘trust’ them…and that’s hard to do. And, you are just one person, and to have 2-4 people ‘presenting’ cases to you for 8-12 hours is just too hard. You can’t think, you don’t know who’s sick…and you can’t physically see everyone and do everything yourself.

And it’s even *worse* when an intern is working. BECAUSE they *really* don’t know what to look for, ask about, check or test for. And when they present to you, the story is often unclear, and you’re left sorta confused. The differential is too broad when the intern presents, and you either have to go see the patient yourself, or ask lots of detailed questions to the intern to get a better story. If the intern didn’t ask the important questions, you either have to send them back to get a better history and physical, OR you order tons of tests/studies to compensate.

Example:

10 month old baby is brought in my mom with a fever to 102.9 x 1 week. Intern presents it as a viral syndrome. Great, discharge, right? BUT they didn’t notice the dehydration and lethargy. They didn’t comment on the petechial rash. So, as an attending you can either:

1) get up and see the patient yourself as if he’s your own (this isn’t very practical if you have more than a couple of residents/interns to supervise or else the flow of the department will be very slow)

2) have the intern order more tests and studies to support the ultimate dispo (which isn’t really teaching, and isn’t really proper EM)

3) you can have a senior resident see the patient, and ‘advise’ the intern. That way, the likelihood of missing meningitis is lower if the senior resident signed off on the intern’s work.

Of the 3 – it’s easier to have the senior resident involved. Also, it’s logical because it allows the senior resident to see more, do more, supervise a bit, and begin managing an entire department. And as attending, you’re there just as back-up for the senior resident. It’s easier to teach the intern if the obvious nuances of the case have been discussed with the senior (at least from July – December). And it frees the attending up to work with the senior and students as well.

The attendings look forward to working with certain residents, just as much as residents like particular attendings. Typically attendings like residents who are confident, do appropriate work-ups, then come to them with their own thoughts about what’s going on, and what to do about it. Then the attending can talk to the resident as an educational ‘coach’ and (almost) colleague about the case. This is fun for attending.

Being stressed out about missing something because an unreliable resident (whether it’s because they’re ‘new’ or just ‘suck’) is telling you half-truths and cannot think for themselves…is miserable.

***

The second way to try and understand what’s going on is to realize that this has nothing to do with you, and everything to do with their own issues:

Imagine you’re an attending…and you’re a bit bitter about your job (for whatever reason). Really, you don’t want to work shifts, you’d rather get credit for shifts worked, while NOT doing any shifts. BUT, you’re not quite *important* enough for the department to allow you to engage in other scholarly activities…and since they NEED attendings to work shifts, you get more than your “fair share” (for your rank and experience), in your opinion. But you can’t quit, because you need your benefits and paycheck too bad. So you make due.

There are two types of doctors (those who actually are comfortable with themselves, their knowledge, and love to share and can readily admit when they are unsure of something....and there are those who pretend to know *everything* and don't want to answer questions because they feel threatened by the resident who's actively reading, and who, on any given day, may be better-read on a particular topic than the attending).

So let's say I'm the second type of attending -

I don't want to 'expose' myself as interns don't know much about 'the way things work' and instead of just 'going with it' they'll ask:

"why? why? why do we use this drug instead of that drug? why can't we just do the procedure this way like Rivers said? Tintinali's new edition said that we shouldn't use this study, that the new ultrasound technique is better..."

Whereas a senior would be more apt to 'just go with it' as per current local ED culture. And if the senior asks questions, it's more appropriate for the attending to follow-up their question with a 'reading assignment' to be presented the next shift. So the residents ‘learn’ to not ask questions.

So, in short: either this is their way of hiding the fact that they don’t know something….OR they’re acting out because they don’t want to be in the position they’re in….

Either way nothing to do with you.

My advice is: YOU SAY NOTHING! Go with the flow...and do not let the Eye of Sauron fall upon you. Stay below the radar right now. Learn, learn, learn. Shine on the inservice in February.

Next year...maybe say something if you're still so inclined (maybe). It's not worth the risk right now. If you're black-listed, you will have a horrible residency experience. Lots of former residents can attest to this fact.

Can I be cool with my nurses (and they cool with me)?

When I was a medical student, I was quite envious of the nurses.

It seemed like the nurses, from the RNs to the licensed practical nurses, had the best of everything. Their lounge was big. Their area well stocked with food and drinks. They were always having celebrations...for everyone...for everything. They made late-night Starbucks runs, and had food delivered to the hospital all the time. And even though they were courteous enough to offer me a latte (sometimes), it always felt weird to 'fraternize' with *them*. They, were them...and I was *us.* "You cannot trust 'them,'" I was told. "'They' will throw you under the bus first chance they get!"

So, for years, I had an awkward relationship with the nurses. If I needed them to do something...how do I ask? "Um, excuse me Nurse, did you see my order?" Or, "Ms, I mean, Nurse Smith...can you get room 1 a bedpan?" It just seemed like...I was asking them to do things...like I was in charge. But they are quick to let you know you're not in charge. But, you kinda are in charge. But you cannot 'remind' anyone that you are in charge...or else you belittle their contribution.

What gives?

Then I realized...as I advanced in my education/training...and as I spent more time as an attending...that good nurses are really there to help make your life easier. If they are not doing that...I would argue that perhaps they are not good nurses. And the thing is, I didn't realize this until I had an *awesome* nursing staff to support me!

In residency, the nurses were indeed a little cult...whose primary mission seemed to be to make your life as difficult as possible. Sorta like they were jealous of a young woman doctor...and resented having to take orders from her. They were not polite. They claimed they didn't know how to do much of anything. "Um, I couldn't start the IV on room 3...so I guess you'll have to come do a central line." Or, "we cannot get blood from Ms. Jones...so you'll have to do a femoral stick." Really?! Really, really! Either you're one sorry nurse...or you're just out to get me.

As you progress, it becomes less acceptable for the physician to perform nurse duties...while simultaneously performing doctor duties. Time becomes more valuable, whereby if the physician isn't seeing patients quickly...someone is losing lots of money (and it's usually someone "more important" in the hierarchy than the doctor). And that...is not tolerated. CEO losing money?! So support staff is hired so the physician can continuing 'bringing in the money.' And this extrapolates to nurses who enjoy (or at least don't mind) nursing.

Fast forward to now. I have a great relationship with my nursing staff in general. Some of it is because my nurses are now there to support me (rather than antagonize me). Some of it is because it is the expectation that the nurses do nursing work. But a large part of the equation is me. I am more comfortable with myself, with my skills, and being a doctor. And because I am comfortable with me, and my role as leader...I am less...awkward. I am more willing to "fraternize with nurses because I realize that being friendly with nurses doesn't undermine me or my role. I see myself as team leader...but I give each member of my team the option to critically think and act without me micromanaging their decisions. I ask their opinion...and I don't feel like "they think I'm stupid" if I don't know something.

And in exchange, they bring their kids in to see me for impromptu doctor visits. They save me a piece of baby-shower cake. They "protect" me from the patients and their families (this is a post for a different day). They sneak me a Tylenol or a Reglan out of the Pyxis when I'm not feeling well. They catch my oversights...and they have my back.




Short story:

Last week I had to reduce a patellar dislocation. SUPER easy to do...but I'd never done one before. So, I gathered my nurse and my tech, and confessed. "Hey guys, we have to reduce this...and I've never done one. So I'm going to read up a bit, then we'll do it, okay?" Amazingly, they were even more excited to learn *with* me. We checked out emedicine. We watched a short video. Gave each other encouragement. And went in the room like we knew what we were doing. Like we did this sort of thing everyday. "Don't worry Mr. Johnson, this will be quick and over in less than 10 seconds" (hopefully). We exchanged glances...smiled a little bit. And did exactly what the doctor did in the video. For about 6 seconds, it didn't seem like it was going to work. But then we heard it. The "clunk" of the patella going back into place! We all exchanged glaces again...with big grins on our faces.

We walk out of the room, and into the back, giving each other hi-fives! WE did it!

How fun is that?! This is what makes emergency medicine a team sport.

Vita-Salute San Raffaele International MD Program. A New Opportunity For Your Medical Education In Milan, Italy.

In this changing world, opportunities periodically come forward in our lives that provide us with a new path to achieve our goals. For those of you that are considering becoming a doctor I want to share with you a new opportunity that you should consider for your medical education.

One of the biggest problems in becoming a physician in the United States is costs. We have watched the cost and debt load for students attending medical schools grow at rates that will make it impossible for many to achieve their dreams of becoming a doctor. This changing cost structure makes it important the perspective students consider all of their options.

We would like to suggest an option for your consideration that will provide you with a cost effective and quality medical school educational opportunity. A place where you can receive a world class medical education, have access to superb faculty and develop international relations that will help you in your future. Plus it is a chance to go to medical school in Milan, Italy. Yes we said Milan, Italy.

Vita-Salute San Raffaele University http://bit.ly/unisr01 is part of the San Raffaele Foundation which includes Hospitals, Research Centers and the Vita-Salute San Raffaele University. San Raffaele is well known worldwide for its excellence: it is a highly specialized center for molecular medicine, diabetes and metabolic diseases, as well as biotechnology and bio-imaging. The Hospital channels many of its resources into cancer treatment, cardiovascular diseases and numerous acute and chronic-degenerative diseases and a very efficient Emergency Department that serves a vast area.

The International MD Program builds on the institution’s solid presence on the international scene: San Raffaele healthcare centers can be found in many countries of the world, including Brazil, India, Uganda, Poland, Chile, Israel, Mozambique and Algeria.

This degree course provides medical-scientific education at the highest level, allowing students to improve their skills and to upgrade their knowledge. It also provides clinical and laboratory research opportunities and additional education in humanities and cultural sciences: philosophy, communication skills, cognitive neurosciences and psychology, which are the building blocks of human society, regardless of social status, race, or creed.

The International MD Program is designed to train a new kind of doctor: someone who possesses the necessary human, cultural and professional abilities to actively participate in health care and share ideas in today’s globalized world. Unlike other Medical Programs in Italy where clinical courses are held in Italian, the International MD Program is fully in English, including classes, lectures, practicals and all clinical activities.

Students enrolled in the San Raffaele International MD Program have access to all the facilities of the Vita-Salute San Raffaele Institute and the San Raffaele Scientific Institute, including skills labs for practical training, a library with more than 20,000 books and several thousand scientific e-publications and resources, as well as to the clinical and research laboratories of the San Raffaele Scientific Institute http://bit.ly/scientificinstitute, the largest private research institute in Italy, that further expanded with the inauguration of DIBIT, a scientific facility for basic, translational and clinical research.

DIBIT is part of the largest biomedical science park in Italy, which includes the San Raffaele Hospital, Science Park Raf, created to support the foundation's development, and the Vita-Salute San Raffaele University.


Applicants who wish to enroll in the International MD Program are required to take an Admission Test.

64 places are available for Academic Year 2011-2012:

32 for EU citizens
32 for Non-EU Citizens.

The Admission Test will take place on April 28th 2011 in the following locations:
Milan, (IT)
New York, (USA)
Kuala Lumpur, (Malaysia)

Candidates who wish to take the Admission Test can visit the following website for detailed information:
http://bit.ly/mdadmissions.

The deadline is April 20th, 2011.

Here are the guidelines on the admission process for A.Y. 2011-2012: http://www.medicine.unisr.it/upload/file/Guidelines%20on%20the%20Admission%20Process%281%29.pdf

For more information on the International MD Program please visit the following website http://bit.ly/mdprogram.


We hope that all perspective medical school students will consider the International MD Program at Vita Salute San Raffaele. It is a wonderful opportunity to earn your MD, learn from an outstanding faculty, develop international relationships and immerse yourself in Italian culture. Opportunities such as this don’t come along often so don’t let this one pass you by.

Ideal job - 6 years out

One of my attendings once told me that it takes about 5 - 7 years for a new ER doctor to master the specialty. This was music to my ears, because I knew that I was *not* confident upon residency graduation to jump into this very stressful specialty. I needed to wade in...from the shallow end of the pool...slowly.

When I graduated, I did not look for jobs that required me to "roll up my sleeves" and do *real* emergency medicine. Contrary to what my colleagues seemed to believe, I realized that I was not quite ready to be a sole doctor in a small town ER, with no specialist support...trying to save lives. Emergency medicine is hard enough in a big city, at an academic institution, with every esoteric subspecialty at your beck and call. The real emergency medicine heroes are truly those docs who work out in Podunk, alone, and really have to do it all!!

So, my first job was at Kaiser. First in Southern California, then Northern California. Kaiser is a very "safe" emergency medicine job. All the patients are insured, they all have primary care physicians, and everything in the ER is protocoled. Oh yeah, and the patients cannot sue you! So if you follow the protocol, you're good. They have all the standard sub-specialists available, and the patients are not that sick. They receive no trauma, and many doctors are working at the same time. So you're not alone, nor are you overly concerned about being sued.

But Kaiser has many drawbacks...and for me was not my long term plan. What Kaiser offered me was...a transition from resident physician to attending physician (on the shallow end). After working at Kaiser, I felt a bit more confident. I actually carried some of their protocols with me, and those protocols allowed me to have "a plan" for patients in other institutions as soon as they presented.

Next, I practiced my wading skills by taking a job with a group who allowed me to work a bit slower at first, and hone my skills. See, the thing is, if you are "slow," you do not make enough money for the group to cover your hourly pay. This means that...the other doctors in the group are subsidizing you. Thankfully I found a wonderful group of docs in CEP to take me under their wing, and allow me to work at my own pace until I developed confidence and personal protocols. (CEP is a great group, but very site specific. Some sites are not willing to "deal with" new docs.) Also, CEP has many sites California, so being with them, I was able to "try" many different sites, and find one that worked for me.

It is common for ER docs to work at multiple sites - sometimes with multiple groups. After all, to have all of your eggs in one basket can be unsettling since we are all well aware of the inherent instability in group contracts and hospital adminstrators. But, working in multiple places allows the new doctor to realize characteristics that are pleasing to them, and those that are annoying.

I discovered that I am not a huge fan of working in hospitals where the clientele is "upper-class." The pay is better in these hospitals, but the patients are not as appreciative, and they are 'entitled' in a way that is really annoying to me. In comparison to rural or inner-city ERs, I find that the social issues in these rich suburbs are similar (such as drug addition, alcoholism, violence) but no one dares to acknowledge these issues lest we upset someone by even suggesting that these issues even exist in well-to-do communities.

Also, in these richer suburban ERs, everything is micromanaged. See, when things are 'perfect' at a facility, administrative hospital staff has to somehow 'justify their jobs' so they *create* problems to "fix." Sometimes these "problems" include...improving upon 99th percentile positive patient satisfaction scores ("let's have the doctors escort the patients to their cars to get that last percentile!") Or, "lets do away with triaging altogether, and promise patients we'll see them within 10 minutes of their ED arrival." Both are bad ideas...

In the inner-city, or out in Podunk, no one has the time or energy to micromanage. There are so many REAL issues for an already overwhelmed admin staff...that every idea is designed to help everyone be more efficient and decrease bad outcomes, period. It is understood that 100% patient satisfaction is not possible, or compatible with running an ER. It is understood that we are all doing the best we can, with what we have, and there is no need to "sell" a well functioning ER to a community. It will sell its self. When "customer service" interferes with the ability of the ER staff to perform their duties...ultimately everyone suffers. Unhappy staff that have better options, leave. Patients who are really sick are not recognized (as everyone caters to our "customers") and good medicine is not practiced as we try to appease every flight of idea a "customer" may have regarding their own care - even if they are wrong!

But I digress.


There are many variables that contribute to an ER docs job satisfaction. Money is a part of the equation. But more than money, is the work environment in total.

• Can I get a patient admitted, or is each admission request World War III?
• Will a surgeon or a cardiologist come in to see a sick patient on Sunday afternoon...or will that patient code and die overnight because they refused to see them?
• Will the laboratory run blood samples timely, or are they constantly "lost" or otherwise "insufficient"?
• Are the patients appreciative, or are they demanding you be their drug supplier?
• Is ER group more focused on pleasing hospital administration and patients, then getting "buy-in" from the physician members and practicing sound medicine?
• Are the ER group members more interested in making as much money as possible apiece than actually staffing the ER safely?
  
• Is the culture of the group to "cover" and switch shifts with each other to accommodate changes in life events, or is finding coverage impossible?
• Do you get to leave on time...or is it necessary to constantly stay late because of inefficiencies in hospital staff...or colleagues who are unwilling to take a sign-out?
• How many nights, weekends, holidays do I have to work...and how are they divided?
• Is the schedule maker respectful of physicians, or are they just pawns who are "in charge of the pencils?"
• Are my schedule requests acknowledged?
• How far in advance does the schedule come out?
• How many patients am I expected to see per hour?
• Are there mid-levels available?
• Is the hospital so close to my house that I bump into patients in the grocery store - and does that bother me?
• What are the nurses like? Do they play well with others...or is everyday a battle?
• Does the hospital allow you to eat in the cafeteria for free? - this is actually a bigger deal than you might think!
• Parking, and call-room access (to take a nap after a long overnight shift before attempted to drive home in rush hour traffic) also demonstrates to physicians their value, and shows appreciation by the hospital admin for the services you're providing at 2am!
• Are you going to be alone in the hospital at times (running ICU codes, delivering babies and such) in addition to managing your ED - and how do you feel about that?
• How long are the shifts? 12 hours? 7 hours?
  
• How are patient complaints handled? Are you guilty until you prove your innocence? Is every frivolous dissatisfied patient's letter taken seriously? Sometimes, a complaint does not need to be passed on. Sometimes, a patient will write a letter, and a polite response can be given, because their gripe is clearly not with inappropriate medical treatment.
  

And these are just a few of the questions that came to my mind in the moment! And each of these issues contributes to physician happiness with a group, and at a site. Getting with "your type of people" is a process of trial and error. And after a few different experiences, I realize that my personality fits best in groups who are a bit more authentic in their practice and in their lives. And this...this attribute tends to be more often present in 'non-rich' communities. I feel more like a real doctor, making a real difference in communities that represent where I came from.


So now, I'm happy working in Podunk, with my lovely nurses...and appreciative patients. I am now on the deep end, swimming without undue fear as an ER doctor 6 years out of residency. As I developed my confidence, I was able to trust my staff more, and rely on them without feeling judged or inadequate (which is huge). I am the only doc in the entire hospital at times (much of the time)...and am responsible for any acute issues that arise. My consultants are fantastic (and NICE), they don't bitch and complain about working...and transfers are not very complicated or time-consuming. I get to eat in the cafeteria for free...and it is not too close to my home where the bank teller recognizes me as the doctor who treated her daughter 2 weeks ago (that was uncomfortable)!


Most docs do not expect perfection in a job...but there are certainly some that are closer to our personal ideal than others.

Finally, (I think) I've found my ideal ER doctor job :)

Difficult Airway

Last night I had this patient...

...He was a 45 yo male with no significant past medical history who presented to the ER in the early evening c/o "I think I have something in my throat." After further questioning his story goes like this:

When I went to bed last night, I felt fine. No cold or flu-like symptoms, no trouble breathing...nothing. When I woke up this morning I felt as though there was something in my throat. Not all the time, but when I swallowed, I felt...like it was hard for the saliva to go down. I tried drinking cold water, then hot coffee, I ate a banana, but nothing seems to "push it down." I decided to come here because throughout the day it's been getting harder to swallow food, and it feels like it's actually bigger.

He denied having any similar prior episode of the same. He denied h/o allergies. He insists that he didn't eat anything prior to the onset of the symptoms (such as fish, meat, chicken, seeds, etc). He had no other "allergic-type" symptoms such as wheezing, chest tightness, rash/hives, pruritis (itching). No new exposures, no travel. He was not a tobacco smoker, or involved in a fire (i.e. smoke inhalation). And he had no symptoms suggestive of infectious cause, such as fever, pain, redness, etc.

On physical exam:
He was a well developed, well nourished man in no apparent distress. Talking in full sentences, handling his secretions without difficulty, and able to drink water and eat soft foods with little effort.

His vital signs were normal, including an oxygen saturation of 98% on room air.
His face was normal, with no signs of swelling, no redness/hives. His eyes were normal without evidence of allergic reaction. His throat exam revealed a left tonsil that appear edematous. But there was no pus, redness, uvula deviation, and there was no pain. External palpation - the left neck felt "full" compared to the right side, but no mass was felt, and again, there was no tenderness to palpation. Lungs were clear. And otherwise his exam was essentially unremarkable.

So...we put him on oxygen, I drew labs (basically because I had no idea if this was infectious, allergic, traumatic, etc...and with airway issues I like to have as much information as possible, just in case surgery/intubation/intervention becomes necessary). I ordered a CT of the neck.

He's cruisin' along, sleeping on the gurney, when I got the CT report back:

"Extensive soft tissue swelling surrounding the airway...with prevertebral soft tissue swelling...partial airway obstruction...."

WTF??!!

I call for ENT, no one is on call. I call the nearest THREE hospitals...and I got some combination of 'no bed', or 'no ENT'. Finally, I get a hospital 80 miles away to take this guy. The ENT surgeon there recommends steroids, IV antibiotics, and intubation prior to transfer. All of that makes sense. Especially since the patient is starting to have more difficulty breathing and swallowing. We'd held off as long as we could to allow the meds to work but...he was indeed starting to have more significant respiratory distress. We preemptively called anesthesia for an awake option since he would absolutely need intubation prior to transfer, but that was now...not an option. Now is the time to intubate...

The critical care transport team will be here in 20 minutes.

So, I round up the troops. Explain everything to the patient; and obtain consent. Move him to big resus room, throw in a central venous catheter (in the femoral vein of course, not going anywhere near the neck). I have my colleagues at my side (2 other ED attendings) with the difficult airway cart at the bedside. I call for anesthesia, but no anesthesiologist is available (which I didn't understand, I mean how can you have an open/certified emergency department without OR staff...including anesthesia, immediately available? But no sense arguing/complaining now). I anticipate a difficult airway. But based on the patient's clinical status, and the fact that there is no one else readily available to secure the airway...we have to try. Or else just watch the patient decompensate in front of us...

We give the drugs, and bag him successfully. Then I try to intubate him. When I look into the airway...all I see is red translucent *pillows*. The airway is completely edematous...and I have no landmarks. I try the bougie, but I think there was too much edema to hear/feel the bumps on the tracheal cartilage...so it didn't help much. My two colleagues gave it a try after me. We didn't want to poke around in there...but we felt like we had no choice but to keep trying. We thought about waking him up, but considering his situation prior to induction...realized that that wouldn't be the best option.

So we ask the nurse manager to call anesthesia again, and if no answer she'll need to call the house supervisor...or anyone that can get an anesthesiologist in here. When I explain to her that we need anesthesia to intubate...she responds with "well they aren't here because the ER doctors usually intubate." But, after unsuccessful attempts by 3 ER attendings, I felt pretty righteous in rolling my eyes at her..and showing a bit of annoyance. Why do I have to explain to her (right NOW) why the ER doctor needs the anesthesiologist? Just fucking do it already!!

With a really shitty attitude, she agrees to keep calling.

So after 3 attempts, it seems as though the guy is intubated. Good color change on the capnometer, good breath sounds. We secure the tiny 6.5 tube. But, he starts to desaturate. Adjusting the tube and bagging him doesn't improve the situation, so we extubate him, and bag him. We are able to bag him!!

The CRNA (nurse anesthetist) shows up (no offense, but I didn't want a nurse, I wanted the physician...someone who can work independent and has final responsibility). I appreciate her presence, and ask her her opinion...but I'm still frustrated, and asking the charge nurse to continue working on getting an anesthesiologist here. And it's even more bothersome that I have to then explain to her that CRNA does not equal ANESTHESIOLOGIST. Sometimes people need to realize that shutting up and doing what's asked is 'what's best for the patient'. This was one of those times!!

We try to intubate again. LMA is at the bedside, but isn't a secure enough airway, and as long as we can bag him...we do that. And of course doing a cric (cutting the neck) is last resort, and since we could bag him...no need to get all messy. The fiberoptic scope is not something any of us ER docs felt comfortable using. There were no other fancy (easy to use) scopes/toys to help us in the difficult airway cart (actually, minus the bougie and the stuff for a cric, the cart was kinda useless, IMO).

We put a tube in, but I suspect the patient isn't intubated properly because oxygen saturation is stable at 97%. When we bag him with *no* tube, he's 100%. Why is he not at 100% with a tube?

It seems like FOREVER, but the anesthesiologist walks into the room (turns out he *was* in house as I figured). I don't think I've ever been so happy to see a consultant in my entire career!! He stands at the bedside, offering suggestions....oh, you're doing a good job...continue....don't worry about the O2 sat, etc.

NO, we're not doing a good job!! Dude isn't even intubated!!!

Initially he doesn't want to get his hands dirty, but after watching the patient desaturate to 96%, 95%, 92%...

...he'll come up, just bag faster, bigger tidal volume, more oxygen.

...90%...88%....

I hand him a pair of gloves. We extubate him (again).

He goes to the head of the bed, does some 'anesthesia stuff' and the O2 sat goes up to 1oo%. What he did was pull the endotracheal tube back into the posterior pharynx, closed the nose and mouth, and bagged that way. Then he asks for the fiberoptic scope...

While that's being set up, he takes a look with the regular laryngoscope...and couldn't see anything!! (I always feel a bit vindicated when someone else tries to do what I couldn't do, and they can't do it either).

Bagging is effective. Now the transport team is here to take the patient to the 70 mile away hospital. But we can't send him without a secure airway.

The anesthesiologist takes a look with the fiberoptic scope...
...and can't see anything!!

(now I'm thinking to myself "wow, I had no chance of getting that airway")

The anesthesiologist asks for a surgeon.

We call surgery, and he informs us that he 'cannot do trachs'.

Now what?
***

So I get on the phone, and call the only ENT surgeon anyone knows that lives in the area (that sometimes works at our hospital). He is not on call, and may not even be in town...but I call him at home anyway. It is now well after midnight.

I BEG him...PLEASE, PLEASE, come in and help us!! PLEASE we cannot send this patient anywhere...and we cannot secure the airway. Anesthesia is here, and cannot get the airway!! The surgeon can't do a trach!! We are all alone!! PLEASE Dr. ENT?!! PLEASE?!!.....

We promise him wine...we promise him gold...we promise to never call him again...
...just please come in now and help us!!

I think he heard the desperation in our voices...and maybe he likes wine, but he agreed to come in!! He asked us to call the OR team in stat. He asked us to set up the patient's ER room into an OR room. He'll be there in about 10 minutes!!

We activate the OR team, we set up everything. The OR staff is there in the ER, setting up the room before the surgeon arrives. Then *he* arrives...the ENT surgeon. To save our asses. The anesthesiologist is able to maintain ventilation by using his 'tube in pharynx' technique. We are all so very relieved...as if a boat has been sent to rescue us off a deserted island!!

The ENT surgeon does the trach in the ER. Anesthesiologist controlled the airway throughout the procedure with respiratory therapist.

Before I even complete my documentation, the patient is gone up to the ICU!!
***

I'm so grateful that this ENT surgeon, who was not on-call...may not even get paid for coming in (since the patient had no insurance, and medicaid doesn't pay sh*t)...and will likely be tired the following day at his profitable private practice clinic...agreed to come in and save this guy's life!!

This was my first time dealing with a truly difficult impossible airway (and I did anesthesia prior to emergency medicine...AND I trained at a Level I trauma center in Los Angeles!!)...

...and never had I seen a situation like this!!

**let me add: This is just a story, not an M&M. Medically people have been trying to dissect this case, but it's not (get this) an actual case.

It's a story.

The point being...the ENT surgeon who was not on call, came in anyway...and saved this patient (despite not getting paid, or otherwise benefiting personally, and maybe even professionally, in doing so). We create (and change/disguise) cases all the time to exemplify or teach a point - and this is what I've done, and will continue doing...to make the point. To create dialogue, and entertain. This case is somewhat unique in that more and more the specialists are actually *not* coming in (for anything), and lots of people die as a result of this all across America...

...this is the unusual case with one that did.

filling my time with less frequent blogging...

I heard that blogging can be hazardous to your health.

It's interesting, because blogging can be stressful and overwhelming...especially if you're expected to produce new material more often than you actually *have* new material. After blogging about a year (more-or-less consistently), I find I have ranted and fussed about most of the things that bother me most (but don't fret, I still have a few annoyances I'd love to expose...and new annoyances things are always "coming up"). I have shared my enthusiasm for my profession. I have documented the process, the thoughts, and the transition from medical student to attending. And I've talked about memorable (pseudo-)patients. Now, I don't feel as pressured to write all the time.

Additionally, it's takes quite a bit of time on the computer to post even one (legible/comprehensible) entry. To translate your thoughts to print...and make them comprehensible by most who'll read them...takes time (depending on the thought). And, I've seen hours "disappear" as I update my blog, surf the net, return email, etc...all while the kids are on their 8th episode of SpongBob SquarePants of the evening (just kidding...kinda).

As the days get longer...and the weather warmer...and the kids get bigger (i.e. more activities, more time needed to engage them, more friends over, etc)...I think I'll have to spend less time on the computer. When they were in bed by 8pm - and me not until 11pm...I had lots of time. But now the little guys aren't in bed until 10pm (it's actually still light outside until almost 9pm in the summer here). So, I have less time to waste spend on the computer.

Just thought I'd post this for those who may wonder 'what happened?'.

Just enjoying the sunshine...

What was medical school like? Years III and IV

After completing years I and II, you have a small break. At our school, this break was only a few weeks....and it wasn't really a 'break' at all.

After completion of year II, it was required that we take (and pass) the USMLE Step I. This first part (of a three part series) tests your basic science skills. Basically, the things we learned in years I and II are being tested. Our school was pretty good about teaching to the test (somewhat), and boasted a high first time pass rate. But you see, that 'break' was spent cramming for this licensing exam.

This exam was very difficult. You know, one of those exams that you can't even discuss afterwards because there were just so many uncertainties. You have no idea how you did. On other exams we've taken, most of us had a feeling about it:

"I think I did okay...but number 10, you know, the question with the xray...I wasn't sure if they wanted this answer or that answer...etc.'" OR, "that exam was horrible...what?! you put C for number 4?? geesh, I musta missed that one too...etc" (like this). After this exam, it didn't happen.

When I took the exam it was 2 days long...all day (except an hour for lunch). After lunch on day two...I just started marking everything 'B'. I was so tired of testing.

After you take that exam, you begin your third year. By now it seems as if everyone knows what they wanna specialize in. And if you do, that's a good thing. The sooner you know, the better. No one told me that...and I wish they had. If you know you wanna be, say ophthalmology, you can engage in research, and start kissing ophtho ass early. You'll take the rotation as soon as possible...and as many ophtho rotations as necessary to get the letters you'll need to match.

Years III and IV consist of clinical rotations.

Our 3rd year rotation schedule was made for us (i.e. we didn't get to choose the order of rotations). Basic required rotations were surgery, internal medicine, psychiatry, OB/GYN, family medicine, orthopedic surgery, pediatrics, and neurology. Our 3rd year consisted of these rotations. Most were about 6 weeks. You had about 12 weeks (maybe it was 16 weeks) of vacation. You could take that as a block, in two 6 week blocks, or however you could manage it. You requested your vacation time...and the university filled in your 3rd year schedule around it.

Our 4th year (frequently referred to as a 'sub-internship') we did our own schedule. There was a second round of required internal medicine...and many of us didn't necessary get all of the 3rd year (required) rotations completed in 3rd year (maybe because of vacation request, or scheduling, etc). So, you had to finish up those. Many of the rotations (the 'interesting' rotations) required the student to have completed a prior 'basic' rotation. For instance, an NICU (neonatal ICU) rotation will no doubt require the student to have completed pediatrics (and possibly OB/GYN) prior to starting. During this year, students typically take rotations like radiology, anesthesiology, emergency medicine, ophthalmology, dermatology, and maybe some bizarre elective at a far away place (but these electives are hard to get approved, and most students opt for pre-approved, 'normal', nearby electives). Also, you get to choose which hospital you'd like to do some of the required rotations. University hospital, County hospital, Community hospital, etc. There are some rotations that are notoriously easy (meeting like twice in 6 weeks) for an easy pass, and a nice break. I (am not ashamed to say it) *maximized* these opportunities. ;o)

During the rotations there are weekly lectures that your school 'requires' you to attend. These are usually very welcomed "breaks" from floor work/scut. Every day the students would try to get out of evening rounds by announcing: "uhhh, we have lecture this afternoon..." The residents and attendings were made *very* aware of the requirement of students to attend lecture...and were powerless to say or do anything except let us go (but beware, they'd sometimes verify that we're actually at lecture). Additionally, there were morning rounds, grand rounds, attending rounds, sometimes evening rounds. Lots of time in 'meetings'...really makes for along day when there's lots of scut to do.

The lectures were by in large *very* useful. And, in retrospect, I'm very happy I attended most of them. Learning pediatrics while doing a peds rotation...really solidifies the information. At the end of the rotation, there was an exam (on the lecture material). Some schools use the shelf exam, thankfully ours didn't. We had exams written by our professors. Everyone passed...eventually. You could take the exam multiple times, until you passed. Every (required) rotation had an exam.

Also during this time we had to take an OSCE (like a fake/simulated patient encounter). Completely bullshit (even in retrospect), where they bring in actors to play patients, and you're graded on how well you "play doctor." I hated "playing doctor." And I hear that this bullshit OSCE is now apart of the USMLE?? Requiring poor (literally, poor) med student to cough up money to take this BS? (but I digress...)

As a 3rd year, your presence on the team is largely unnecessary (despite what they tell you, and regardless of the student's arrogant belief to the contrary). You slow down the intern/residents; and all of your orders (rightfully) have to be cosigned...hence they are useless. In clinics you're really annoying to the people actually 'working.' In-house on the floor, the patients think you're 'cute' and they always 'know someone, who knows someone, who 'gonna be a doctor.'' And instead of telling you their deepest concerns and intimate medical issues...they wanna talk about *you.*

In retrospect I realize that much of that...that inability to be taken seriously by patients was my fault. I was insecure, didn't really know what to ask. My history was unfocused. AND I actually sat there with them for hours getting largely irrelevant information...which made me their "friend" and not their "doctor." (which is okay since I *wasn't* a doctor...).

The various rotations differed from each other tremendously (and I'll discuss that on a different post). But, in general, to do well in the clinical years involved working smart - and the realization that you're really gonna have to make some time sacrifices during those rotations that involve the specialties you're actually interested in applying to...because they will haze you.

Let's just take internal medicine as an example:

To do well in internal medicine you should try an be apart of the team. That means not leaving too frequently to attend "lecture" or whatever. That means arriving before everyone else does, and leaving after they do. When you have patients assigned to you, realize that *you* are not managing the patient - the attending and residents are managing the patients, and you are doing what they tell you to do. Your role is to listen and learn. But more than that, having assigned patients means you're responsible for *information gathering* for those patients. As a 3rd year (and 4th year...and intern) YOU ARE AN INFORMATION GATHERER.

Some will tell you to 'know everything' about your assigned patients. Well, that advice didn't help me much because, on a practical level, that is not possible. Better advice would have been as follows:

You come early and get the lab values (know the trends), the radiographs/results, the medication list with the antibiotic day number, fluid intake/output/weight change, any overnight events on the nursing note or per the patient. You should know what the physical exam shows (new rash? pressure sore? crappy lung sounds?) You should know the vital signs, and if any fever spike overnight (and if so, what time). You should know if any orders had to be written on your patient, why, and if what was done helped. You should know their bed number (and if they were moved, the new bed number, and why they were moved). You should know their working differential diagnosis...and do some reading about the disease(s) and how to treat them, what complications to expect. You should have written the daily progress note (to be completed after you are told by your team what the assessment and plan are). And you should anticipate (or have the handbook) of possible questions the attending will ask...and know the answers so you'll look like a star.

Your school will let you know if overnight call is required. There needs to be a place for you to sleep, and something for you to do. The nurses may (or may not) be instructed to call you first. And if they don't, well...it's kinda no point for you to be there. Especially if your orders all have to be cosigned. The intern will have to take every call, and write every order anyway...

...but at some community hospitals I rotated thru, there were very nice call rooms for everyone...and the nurses *did* take student orders...and they *did* call the student first (usually these are 4th year rotations where you're working as a sub-intern). It's easier to stay on-top of your patient information gathering duties if the nurses call you when there's an issue. And you felt important. Also, typically OB requires overnight call for obvious reasons.

Exactly what do you do all day?

Well, you go in early (whatever time makes you the first person there). You go physically look at your assigned patient (usually you'll have 2 or 3). Make sure they are alive, breathing, and are still in the location they were yesterday. If they are awake, ask them how they feel. Be sure they know you were there (this is more important as an intern and beyond, sometimes patients will complain that 'their doctor never comes by and see them' not realizing that *you* are the doctor...and see them multiple times a day. You can't have patients spreading rumors like that about you). Put a stethoscope on their chest. Pull back the covers gently and make sure there's nothing obviously wrong. Do a focused exam - meaning, check the part of the body that's causing them to stay in the hospital. Note any changes.

Then you have your paper/index card for that patient. You write their room/bed number on top next to their name and medical record number. Then you grab their chart and flip thru it...looking for the information I described above. Look at the nursing notes...and read what they wrote overnight. Look at the vital signs sheet for the last 24 hours. Look at the order sheets and see if/when anything was ordered. Read the physician progress notes, and note anything significant. Be sure to look at the medication list. Check the labs, and remember to check for any positive blood/urine/sputum cultures. Know the medication allergies. Look and see if any of the consultants wrote any (new/old) recommendations. Then, write your note with all of this information incorporated SOAP note style (leaving the AP blank until after rounds). If your note is good, only the attending will have co-sign, and it'll count as an official note (i.e. the intern won't have to write a full note, and they'll be happy).

Do this for every one of your patients. And with any time left over, you go eat, and read a bit about the diseases your patients have (and what to make of any overnight changes).

If your hospital still has plastic xray films, you should find them, and gather them. Carry them around for the attending to look at. If you have a pacs (digital) system, log on (or have someone log on for you) and look at the films. Look for any radiologist reports...and look at the images yourself. You should be able to identify any significant changes between today's xray, and the one taken yesterday. Lungs more white? Kinked chest tube? Free air?

During rounds you present your patient the way the attending likes it. Be sure to at least mention (to someone other than another student), things that *you* think are important, but couldn't say on rounds. Remember, rounds isn't always about learning or information exchange...sometimes, with some attendings, it's about providing them a platform to flex. They may not appreciate someone like you making them 're-focus' on patient care.

Many teams will have short 'okay-this-is-the-*real*-deal' rounds after the attending leaves. Where the work is divided. Then everyone goes to morning report/rounds. Morning report is a lecture where an intern presents a case, and everyone does this mental masturbation exercise about the patient.

Then it's time to work. Most hospitals where residents exist aren't very efficient. The nurses don't do shit...and the students/residents do everyone else's job. This is what takes forever. This is the problem with resident education. This is why it seems as if the surgeons aren't as well trained with restrictions in place...eventhough they're in the hospital 88 hours a week. Are the surgical interns/residents so stupid that they cannot learn what they need to learn in the 88 hours/week, 5-7 years they're there training?? (I just love what the medstudent tells Bongi in the comments section of this post). Of course not!! They aren't doing all the necessary *doctor tasks* to properly train because they spend 90% of their time doing other people's work and miscellaneous non-physician/non-educational/irrelevant bullshit. Drawing labs. Finding lab results. Pushing patients to scans/xrays. Finding xrays. Massive clerical work. Trying to plead with hospital staff to do what they're supposed to be doing for the benefit of the patient (so they can get that study done, or that consult completed...so everyone can go home). Residents/interns play social worker, trying to discharge patients with no place to go. And during it all while being constantly interrupted by pagers. Some of the bullshit is unavoidable, but much of it can be changed if the higher-ups were really interested in change and patient safety...while maintaining the high quality of the doctors being produced.

But instead, they advocate for unrestricted resident hours...

Unwritten rules include:

it does you no good to make your fellow student, the intern, or resident look bad in front of the attending. If the intern is asked a question by the attending on rounds, and s/he doesn't know the answer...don't you jump in and blurt the answer. You say nothing...unless the attending directly asks "does anyone else know?" And still you wait a minute. I would advise that 'if your superiors don't know, then you don't know', period. If you are smart and actually *do* know, it will show in different settings - such as when you concisely present your patients to the attending with a focused differential, and the subsequent pimping session proves you know your shit; or when the attending asks you a question first and directly and you *modestly* give a correct answer. You do not get cool points from anyone being a smarty-pants know it all. And if one of your teammates doesn't know something about his/her patient, you can tell them discreetly, but never one up them on their own patient in front of the attending. And, please, *never* ask questions that you know the answer to. This annoys everyone!!

It's best to not talk negative about anyone. That can only come back and bite you in the ass.

On rounds you follow the pack. You stand if chairs are limited. You carry all the crap (the stethoscopes, the otoscope, tongue blades, whatever is commonly needed but not commonly easily obtained). You don't argue. If someone says you're wrong, you're wrong. Even if you're not wrong...just forget it. If you want honors, and a match into the specialty, you'll realize being 'right' doesn't matter.

Many times inappropriate comments were said (especially on surgery), and may put you in a difficult spot. Usually some sort of sexist jack-ass with a small dick blurts out some off the wall comment about women...but sometimes it's even more hateful than that. It was not unusual for surgical attendings to throw full-on (two year-old type) tantrums. Surgical instruments thrown across the OR because anesthesia had the table too low. Or verbally abusing everyone, just to see how many times he can make the resident cry.

What seemed to work well at our school - a group of students who agree that the person is out-of-line would go to our student affairs dean and complain because it's never just one episode of ignorant behavior, and many people can usually agree that the guy (it's usually a guy) is an ass. We'd express our concerns, and demand to be moved to another team, or another service, or another facility. Usually, if there was a (big) problem, you could be moved (as it should be being that you're paying up the ass for an education). And on more than a few occasions, students were not placed on certain teams, or with certain attendings with a reputation for being assholes. But realize that as an intern...the solution is not so simple.

Offer to do a presentation for the team. Bring in an interesting journal article (if you happen to find one), and educate the team about it. Have a happy disposition. Be reliable. If your intern relies on you, you cannot miss attending rounds...because they will not know the detail about the patient that you know because they were *relying* on you to know (and be there). (Even if you're sick, you need to come in for attending rounds...then ask to go home). And don't leave until all the work is done...or at least ask if there's something you can do to help out the 'slow-poke' before you leave. Usually the answer is "no", but if you acknowledge that they are still there, and offer the help...it will be noticed.

In order to graduate from our school the USMLE Step I must be taken and passed. USMLE Step II is taken during senior year. It does not have to be passed to graduate. There are strategies as to when to take Step II. Some do it early to make their application competitive. Others do it later, as not to tarnish an already acceptable application. It depends on the competitiveness of the specialty, and the competitiveness of the student. Also a consideration, if you did awesome on Step I...you may not want to take the chance that your Step II score will be lower, and some of your shine is lost.

USMLE Step II is easier (more practical information), than Step I. It was also 2 days long. Exam topics are those of the basic rotations - peds, IM, psych, etc. Some specialties consider the USMLE score to be the single most important part of the residency application.

***

Overall, in years III and IV you have much more control of your time. Only a few rotations are brutal, and only being so because of their long hours and the amount of scut (i.e. gathering information, and pushing the patient along in the hospital diagnostic/treatment process) required. Some rotations will be more stressful because you're trying to impress the staff. Usually, by mid 3rd year everyone is pretty sure what their interests are...and it's no secret to surgery residents that you're not into what they do. And they don't torture you as much.

You have time now to see a movie. The tests are easily passed with a day or two of studying. Even the USMLE has great prep material out there such that you don't have to study much more than a 150 page book and do well (enough). If you're a good team player, and do well on the exam, you'll honor at least a few (maybe even most) rotations. If you do very well, and people really like you, you may be inducted into the honor society, AOA. AOA on your CV looks very good to program directors of competitive residency programs. Also, you have time to engage in some research (not alot of time, but *some* time). And some students will take a year or two off after 2nd year to do research (or have babies, or travel, or get an MBA, etc). This will also look good on your CV (well, maybe not the 'have babies' part, but that can be disguised as 'research' if done correctly).

Many medical students decide to have children during 4th year. Some do away rotation in Costa Rica. Some take no vacation...and save it all to the end (this is what I did). This was fantastic since my last rotation ended in early February, and I had 'vacation/freetime' until I graduated in mid May!!

That was my last 'summer vacation.'

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p.s. so, now that you understand what medical school is (sorta) like...you'll appreciate the (hilarious) humor in these videos on my sidebar:

This one. This one. and this one. (you just have to see them all. After the first one plays there's an opportunity to watch the others...)

I'm LMAO just thinking about them!!