Along with surgery, the obstetrics and gynecology rotation is one of the most fear-inducing clerkships that a medical student will encounter. It, too, is filled with long hours in which lots of patients have to be seen, prepped for surgery, and then operated on. I took my ob/gyn rotation after family medicine. Making the switch from getting up at 8:00 a.m. to getting up at 4:00 a.m. hit me pretty hard.
The inpatient gyn section of the rotation is very similar to surgery. The attending yelled at residents for not knowing minutia. The residents in turn yelled at the intern for not anticipating the desires of the superiors. And the medical students got ignored and were forced to stand in the back of the room when examining a patient. While a simple hysterectomy can be performed in under two hours, some of the oncology surgeries would go well beyond the eight hour mark as we removed the entire pelvic anatomy of a woman stricken with ovarian cancer. And I use “we” in a loose sense. In reality, I sterilely stood to the side and watched as an attending muttered profanity under his breath with each blood vessel and ligament encountered. So long as you remember the details and advice from the Life Raft for surgery article, you should be fine on the gynecology section.
The real highlight and breakaway comes when you do obstetrics. Obstetricians have vast medical knowledge regarding drug effects on fetuses, the day-by-day timing of embryonic growth, and carry with them enormous patience for a woman in labor to finally hit the delivery point. At my hospital, medical students are required to deliver at least one baby during the rotation. Unfortunately, there is a turf war going on between midwives and obstetrics residents for delivery time. I may spend an evening on call working with a patient in labor in the hopes that I might get to perform the delivery, only to have a midwife shove me out of the way and tell me, “She’s mine, bitch!”
It’s kind of like when I’m at a party and trying to pick up the attractive girl, only to have her fat friend show up and say, “We’re leaving! No one wants to talk to me.” And just like that, all of the work on my behalf is gone. But so long as you are persistent, you should eventually get to catch a baby on your own.
First, never examine a patient on your own, even if you are female. There are lots of nutty people who come to the hospital with their own expectations. You might be performing an internal exam to check for STDs, positioning of a baby’s head, reasons for vaginal bleeding, or whatever else you can think of—only to have the patient accuse you of sexual assault. Find a nurse for another medical student and have that person chaperone you when you are performing a physical.
Second, when you find a patient that you want to perform the delivery on, introduce yourself many hours in advance. Granted, some women who choose to go to county hospitals for delivery don’t care who delivers her baby, much less who knocked them up, but it’s still the polite thing to do.
Finally, make sure everything is ready to go for the delivery—even if the baby isn’t due for another six hours. I had everything laid out on a table in case of an imminent delivery because there really is no way to predict when the baby will arrive.
Few fields of medicine are as unique and exciting at psychiatry. Where else are you going to find a 34-year-old man talking to his penis and telling it secrets? At the end of your shift you will come home wanting nothing more than to tell all of your friends and neighbors about all of the interesting people you’ve met throughout the day. Don’t go breaking HIPPA and other codes of decency just yet. There are several important rules of etiquette that apply more so to psychiatry than to any other specialty.
First off, never say that a patient is “crazy,” “bizarre,” or even “psychotic.” These terms stigmatize mental disease and place blame on the patient for a neurochemical disorder that could just as easily affect any one of us. Instead used terms like “inappropriate behavior” or better yet, cite specific examples of things that the patient does, such as “responding to internal stimuli.”
Second, never say that a psychiatry resident is “crazy,” “bizarre,” or “psychotic.” For whatever reason, the strangest people in medical school generally end up as shrinks. And as the book Mount Misery tells us, psychiatrists will specialize in their defects. There are many stigmas against the field both within medicine and among the lay public. And you certainly don’t need to contribute to them.
Television shows such as Dr. Phil leave us believing that anyone can treat mental disease and has turned us into a nation of armchair therapists. Encroachment on the field by social workers, life counselors, and a variety of psychologists who use any title such as “school psychologist” make the specialty seem easy to enter.
Among other physicians, psychiatrists are seen as being helpless to treat medical conditions. I wanted to apologize to our consultants every time we had to call them because our residents could not manage blood pressures of 150/90. Whenever a patient attempted suicide by cutting his wrist and then presenting to the psychiatric hospital, he was immediately deferred to another physician to suture the wound closed. The other specialists were generally greatly annoyed that anyone with a title of “M.D.” could be unable to manage mild hypertension or mildly elevated blood sugars.
What you need to know to succeed on your clerkship:
1. Drugs, drugs, drugs. With the exception of electroconvulsive therapy, there are no procedures to master in this rotation (as if you’ll even see ECT during this rotation). The sole method of treating mental disease amongst psychiatrists is to use an armory of medication in the hopes that the various neurotransmitters are put back into proper balance. I suggest that you either find or make a list of various psychotropic medications, their mechanisms of action, their indications for use, and the side effects specific to each drug. Such a list of drug names would not be very long, but should contain a detailed amount of information. For example, clozapine is a very effective medication against schizophrenia. However, its most dangerous side effect is agranulocytosis. I can guarantee you that you will be asked about this drug at least once.
2. DSM criteria for diagnosis. In psychiatry, the majority of diagnoses are made solely upon history. There is no physical exam, and anyone who tells you otherwise is lying to himself. There are however a battery of paper-based scoring test that are used in the management of a patient’s condition. Rarely are labs ordered. If they are, look to order electrolytes, a thyroid panel, vitamin B1, vitamin B12, urine toxicology screen, and an RPR to test for syphilis.
Several months ago I posted my stories about psychiatry on this website. They generated quite a bit of discussion amongst my readers. Here are my previous posts. I hope that they can create new conversations amongst all of you.
You won’t believe the stuff I saw today
Everyone gets a diagnosis and a prescription
Psychiatrists as shams
You won’t believe the stuff I saw today (part 2)
The fake doctors
How’s that for a can of whoop ass?
You won’t believe the stuff I saw today (part 3)
You won’t believe the stuff I saw today (part 4)
Whereas the surgeons worked you to death, the internists are going to bore you to death. One of the frequent complaints about the internal medicine clerkship is that rounds take entirely too long. My own team would routinely spend about three hours going through a census of only 20 patients. Some of my classmates got thrown into groups which would take five hours every day to run through the list—and that’s after all of the pre-rounding has been completed, orders filed, test results analyzed, and patients reassured.
Internal medicine is the wastebasket of the hospital. All cases that other services refuse to take are deferred to the internists. I remember taking care of patients who clearly had neurological problems, were refused by the neurology service, and then we picked them up only to later consult the neurology team. You will get skin disorders, psychiatric ailments (including suicide attempts), and a variety of elderly patients who are near death’s door, but the family is too ashamed to finally just let them die.
Since internists have to deal with so many different diseases, they acquire a vast body of knowledge and a keen eye for looking at subtle differences between presentations. The internists will then happily share this knowledge to anyone within earshot, commenting on the sensitivity and specificity various laboratory studies, noting the laboratory artifacts that can give positive results for various tests, and devising treatment plans using the first, second, and third lines of therapy.
While I certainly respect internists and their knowledge base, hearing about it can be quite annoying. Internists were the little nerds on the playground who got their asses kicked whenever they tried to say, “But it’s my turn on the monkey bars.” Internists go home and fondle themselves while watching Patch Adams, vowing to one day heal their patients using only their words. Internists like to take out their sick brand of torture known as rounding on others. You’ll very likely sit around the table and toss around ideas about a patient’s medical status. The process is nicknamed mental masturbation because attendings seem to get off on the idea that discussing a patient’s laboratory values is such great fun.
The best attendings will be the ones who treat you as a member of the team. They will force you to get up early, see multiple patients, read about their diseases, and then present the information succinctly on rounds. At the time, they can seem like total hard asses because of all the hours you have to spend preparing for the next day. But the payoff is so rewarding. The worst attendings are the ones who treat medical students like know-nothing observers. Sure, life may be easy when you leave the hospital every day at 10 a.m., but it bites you in the ass when you take your Shelf exam and realize that you haven’t learned anything.
On medicine, your grade is directly proportional to your communication skills. Students who write long admission notes tend to get praised by the boss. For every one of my patients that I admitted, I would typically type up a five-page long note covering everything from the patient’s smoking history, to a differential diagnosis of upper abdominal pain, and a discussion of what the various laboratory tests mean. The longer your note and differential diagnosis are, the better your evaluation. Whereas surgeons use rounding as an opportunity for you to quickly list the facts and then rush to the OR, internists really don’t have anywhere to go during the day, so they use rounds as a way to pass the time. Therefore, you should make every opportunity to deliver good presentations in front of the residents and attending. One way to do this is to think about your patient’s presentation as a story. Your goal is to lead the audience into having the same thought process as you. Mentioning that a patient’s chest pain gets worse with inspiration is far more important than mentioning that he is sweating and has a fear of impending doom.
Whenever you go see your patient first thing in the morning, be sure to do a complete physical exam involving the cardiac, pulmonary, and abdominal systems, regardless of the chief complaint. Being thorough does not mean placing your stethoscope on the patient’s chest and then asking him to breathe deeply. It means that you need to sit the patient up, removed his gown, and listen to the entire back and chest. I’ve seen residents get burned by a patient with pneumonia simply because they wanted to rush through a physical exam and listen to the patient’s lungs only from the front. Waking someone up first thing in the morning and getting him to sit up or at least to roll over in bed takes just a few seconds at most. Missing a patient’s crackles, costovertebral tenderness, or an abscess on the back or buttocks is simply inexcusable. I distinctly remember having an HIV-positive patient with pneumonia who, despite our best efforts with oral medication, was not getting better during her hospital stay. Every morning I would go into her room and check her legs for edema just for completeness sake. One day I pulled off her socks to check the pedal pulses and several pills fell to the ground. She had been hiding away her medicine because she “didn’t feel like swallowing all these pills.” We immediately switched to intravenous antibiotics and she rapidly improved.
Some previous posts on internal medicine:
Let God sort them out
Letter from a patient
Every time a homeless person is admitted to the hospital, an angel gets his wings
The puppets of medicine
All this work, only to be outdone by a bag of Oreos
Looking over my previous post about how to conduct yourself on surgery, I realized that I left out an important point about pre-rounding and presentation on rounds. Part of your job as a medical student will be to wake up all of the patients first thing in the morning so you can ask them about their pain level, bowel habits, and any overnight events. You will also conduct a very short physical exam. Depending on which service you’re on, you might have as many as six patients that you have to see and write notes on in one hour. Since timing is so important, I used the following lines of questioning with every patient:
How did you sleep last night?
How’s your pain right now? Can you rate it on a scale from 1-10? Where is it located?
Any nausea, vomiting, or diarrhea? Have you passed gas?
How’s your appetite?
Did you get out of this bed yesterday to walk around?
Are you using the incentive spirometer? (You should have the patient demonstrate that he knows how to use the spirometer.)
Next, listen to the patient’s heart, lungs, and abdomen. You’re looking for any chance of atelectasis, new murmurs, and bowel sounds. If the patient is on the first postoperative day and had abdominal surgery, you may very well not hear any bowel sounds—hence why it’s so important to ask if the patient has passed gas since the operation. And make sure to do a real physical exam. That means that you will have to set the patient up in bed, if possible, to do a proper lung exam. I’ve seen many residents claim that the patient is healthy when they’ve only listened to the anterior chest. They later get burned when they discover that the patient has a lower lobe pneumonia. Don’t let that happen to you. Getting an immobilized patient to sit up—or even roll over—takes only a few extra seconds.
Finally, check to see what the patient is getting via IV. While the orders may say that the patient is to receive 100 mL per hour of 1/2 normal saline, you might be very surprised to see that he is now receiving 150 mL per hour of 0.9 normal saline. Also make a note of the color of the urine in the Foley bag—whether or not it has any blood, as well as look at any drains. The color of the fluid in the JP drain should be either clear, pink, or green if you are expecting bile. The output in a drain should never contain frank blood, but a serosanguinous fluid is acceptable. I also knew a few attendings that wanted us to change the patients’ dressing before rounds each day. Check with former students to learn the attending’s preferences.
Whenever I’m pre-rounding on a patient, I usually try to find the nurse who took care of him the night before to ask about any overnight events. While your patient might tell you that he slept well throughout the evening, your nurse may tell you that he was up vomiting all night. If the nurse is unavailable, then try to find her notes.
You should be able to complete all of the above steps in less than three minutes.
Now you need to look up all of the patient’s overnight lab work, including any new imaging studies. You should write your note by detailing what the postoperative day is, what was the surgery, all the information that you gathered earlier, and what day of antibiotic treatment the patient is on. Leave out any past medical history. An example note looks like this:
S) Mrs. Smith is a 67-year-old female who is postoperative day number three for a gastrojejeunostomy. There were no acute events overnight. The patient states that she currently has a 2/10 pain level and is well controlled by current medications. Clear liquid diet is well tolerated. No N/V/D. Patient is ambulatory.
O) List your physical exam findings as well as any new labs.
A/P) Give a very short assessment and plan, but focus more on the plan. Examples might be “Advance to soft diet” or “Chest x-ray to rule out pneumonia.”
When you give your presentation on rounds, recite the information from the subjective part, list the vitals, mention only pertinent findings from physical exam—otherwise just say, “heart and lungs sound normal”—and then give your plan for the day.
Rounds stop being nerve-racking around week two.
Addenum: Someone pointed me to the surgical review by Pestana. It looks good, but given that I don’t know the copyright status of the outline, I’m hesitant to post it here. You’ll have to do a search for it.
I wanted to kick off this series by discussing surgery. Few rotations are as anxiety-provoking as this one. You can expect to be at the hospital by 5:00 a.m. every morning with plans that you’ll stay put for the next 12-14 hours. You’ll have to come in almost every day on your rotation, and that includes weekends. Expect to spend 80 hours a week in the hospital. You should kiss your loved ones goodbye because as far as they’re concerned, you’re going to be gone for the next eight weeks.
To excel on surgery the first thing you need to do is become very familiar with the reasoning behind the procedures. Attendings don’t care if you know how to remove a gallbladder. They will, however, expect you to know what are the indications for taking one out. If a patient has right upper quadrant pain, what’s the differential diagnosis? How would you know that someone has cholecystitis versus pancreatitis? What do you look for on ultrasound? What are the findings on the physical exam? What labs should you order, if any? How urgent is this procedure? Are there any alternatives to this procedure, including medical ones? What are the risks to a cholecystectomy? If the resident in the case prematurely cuts the bile ducts, what do you do then? What’s some of the relevant anatomy in that area? That is, what do you have to watch out for during surgery? Once the gallbladder is removed, is there any chance for recurrence of disease?
Those are just some of the questions you should be able to answer any time you go into an operation. And if you’re dealing with cancer, you should know all of the relevant tumor markers as well as their half-lives. The half-life is important to know because it gives us an indication of how long to wait before retesting the patient.
The second expectation that attendings will have is that you can manage hospitalized patients. You should do some reading on fluids and electrolytes because those issues become very important once a patient comes out of surgery and cannot eat for several days. You should also be aware of your patients’ conditions at all time, including urine output, feedings, any fevers, relevant labs, ambulatory status, and pain level, just to name a few. Some attendings are also very big on wound care—so you should always carry gauze, tape, suture removal kits, staple removal kits, and a pair of scissors.
In addition to the general etiquette that was discussed earlier, there are several new behaviors you will have to acquire on this rotation. First, you should address everyone as “ma’am” or “sir.” That includes the nurses, the techs, and all of the residents and attendings. For some reason, surgeons believe that medicine should be run like the military. Granted, none of them had ever served in the armed forces, but I certainly heard a lot of attendings say, “This is just like the military.”
Second, do not speak unless spoken to. If you have a question, you should keep it to yourself and look up the answer later. I cannot stress this point enough. Do not ask your attendings any questions regarding any disease is that you may encounter. You’re attending will very likely turn the question around and either pimp you or force the resident to answer. Then you’re going to be stuck with the resident that dislikes you and a comment on your evaluation that says “The student needs to read more.”
Finally, you’ll have to start introducing yourself to everyone in the OR. Whenever you head into a case, immediately let the circulator know who you are. You should also introduce yourself to the scrub tech, as he/she will be passing you instruments throughout the operation.
As I mentioned earlier, the attendings aren’t looking for you to learn surgical technique. Very likely your experience in the OR will consist of holding retractors and cutting suture lines. If the surgeons take a liking to you, they might let you place the closing stiches. In that case, it pays to be knowledgeable in advance on how to tie knots. Hop on over to YouTube and watch a few videos on the subject. You can then practice at home using old suture line obtained from the scrub nurse.
In addition to all the amount of time you’re going to spend in the hospital, you should devote about 10-20 hours a week for reading. The most popular textbook for a surgery clerkship is Lawrence. However, I found the book very difficult to get through. Students generally like Surgical Recall because it preps them for all the pimping that they’ll inevitably receive in the OR. Unfortunately, there’s not a whole on out there that does a good job of preparing you for the Shelf. This exam is very difficult because it covers a wide range of topics on everything from breast cancer to skin cancer to electrolyte management to ethics. The good news is that there is no anatomy on the Shelf.
All across the country this week medical students are coming back from their Step I vacations, dusting off the collared shirts and neckties from the back of the closet, and putting on pristine white coats as they head onto the wards as new third years. I want to congratulate all of you M3′s on getting this far. If you’re like me, you’re probably totally lost at this point as far as what your responsibilities are on your clerkships. I’m creating a new series called The Life Raft where I will move step-by-step through each rotation to tell you about your responsibilities, etiquette, what books are useful, and some general tips that will make you shine.
Before accepting anyone’s advice you should look at his qualifications. So, I feel that a bit of self disclaimer is necessary. I went through eight clerkships this year and earned honors on several of them, including getting the highest grade in the class on one rotation. Out of the 30 or so evaluations that were filled out by residents and attendings, all but one of them were for honors. Consistently my biggest struggle has been with the Shelf exams. I won’t be giving out any advice on how best to prepare for the tests. Instead, my goal is to make you a star on the wards.
There are some rules you should observe regarding your interactions with your teammates and teachers. First, realize that you and the rest of the medical students make up a team. You are partners. And unless there are any glaring differences, you will all generally be looked upon with either the same high regard or disgust. Therefore, you should do whatever is necessary to make your teammates look really good. You should alert your teammates to any changes with their patients. An example is if you have to stay till eight o’clock because of a late surgery and discover that someone else’s patient suffered a code at seven, you should call your teammate to let him know what happened. He’ll need to be prepared when he pre-rounds next morning. He certainly doesn’t need to get caught off guard with any surprising information when he arrives to the hospital at 5:00 a.m. the next morning.
Second, give teammates credit when delivering presentations. Whenever an attending posed a question to the group and told us to look it up, I would present the information the next day and state that my partners and I all played a role in researching the topic. My teammates ended up paying back the favor and cited me to make me look good on rounds. What the attending sees is not a group of students who individually hunt for data; he’ll see a cohesive team where members teach each other and work well together. The end result is that everyone gets high marks. If you’ve ever heard of the prisoner’s dilemma, the same situation applies here.
In short, the prisoner’s dilemma states that the best result can be obtained by forgoing a large reward and helping yourself and your partners obtain smaller rewards. The reasoning behind this action is that if everyone is searching for the largest reward—e.g., “I want to get honors and no one else should”—teammates will begin stepping all over each other, will make each other look bad, and then no one gets a reward of any kind. I’ve had several attendings tell me at the end of the rotation, “Your team is so great. I’m going to give you all excellent evaluations. You’re much better than many of the other students I have seen around here.” In reality, I don’t consider us that much better at all. I think that we showed up on time, knew about our patients, and did our work for the day. The only difference is that my teammates felt the same way I did. I will say that I’ve been lucky in that regard. I’ve heard horror stories from my friends about lazy partners who make the whole team looked bad. Nothing is worse during third year than a dysfunctional team. I’m lucky enough to have been shielded from much of that.
The final piece of etiquette is that you should never say anything bad about other students, residents, or attendings. Even if you have the world’s dumbest intern—and your attending openly calls him that on rounds—you should never say the same thing. Remember what I said earlier about making your team look good? The same rule applies in a way that you treat the house staff.
You should also go so far as to never make fun of other specialties. While I admit to making a lot of disparaging remarks about different specialties on this website, you should realize that this is just an anonymous place for me to vent. I would never call a psychiatrist a fake doctor while I’m in the hospital. You just never know who you’re talking to. While you’re ragging on shrinks in front of your surgery attending, he might feel a little insulted if his wife happens to be a psychiatrist.
With that said, this concludes my introduction to The Life Raft. Hop on over to the downloads section and pick up a patient tracking sheet that you can use on rounds. Welcome to third year. You are now a Half M.D.