I caught up with the Dean of the Medicine recently to talk about the way our medical school is run.
Half MD: Thank you for agreeing to this interview
Dean: No problem. I know that pre-meds read your blog and will find this information useful.
Half MD: First question—why does our school put so much information on physicianship training, while ignoring other classes such as microbiology? Our university’s board scores are pretty mediocre, and I think it’s due to the curriculum.
Dean: We put so much emphasis on physicianship training because those are the real skills that you need to know to become a doctor. Learning the proper grip to use when holding a patient’s hand is far more important than memorizing a list bugs and drugs. Further, the only time we can ever teach you about bedside manner is during the first two years. As for all of that other trivial information such as microbiology and pharmacology, we figure that you’ll learn it on your own while studying for the boards.
Half MD: I’m currently on my surgery rotation. While there’s a lot of information to learn, why do surgeons have to be such assholes? Isn’t there a better method for teaching than negative reinforcement?
Dean: Surgeons are the playground bullies of the medical world. Any compassion and genuineness has been beaten out of them long ago. They’re so used to talking to others through screaming that their encounters with students and residents are rarely pleasant. That’s not to say that all surgeons are like that. Urologists and Ophthalmologists bring civility to the medical community.
Half MD: I’ve noticed that a lot of the “rules” are broken on the wards. For example, students have to come in a 5:00AM to pre-round on patients, despite being told by the clerkship director that students are not supposed to pre-round.
Dean: There’s a lot of that in the medical community. He told you not to pre-round simply because he’s required to. Yet look at his own students. They regularly arrive before 5 and will spend over 80 hours a week in the hospital. The residents goes through a similar process. Do you know of an intern who spends less than 30 continuous hours in the hospital?
Half MD: Is there any way to save my backs and legs during long procedures? I would love to bring a stool into the OR.
Dean: Mentioning that you’re tired will only make you seem weak. You can try hidden methods of relief. Compression stockings, shoes with high arch support, and regularly changing your socks will help a lot in the long run.
Half MD: Although I have no desire to become a surgeon, I’m still eager to learn. I’ve tried to get opportunities to do simple procedures such as starting I.V.’s and suturing patients, but no one wants to teach me. I even offered to insert a foley catheter on a patient in the OR. Our nurse said, “No, I don’t want you slowing us down.” Given that we were already an hour behind schedule, I don’t think taking 2 minutes to insert a catheter is going to make things worse. Why are the nurses so rude on our service?
Dean: They’re only rude to medical students because they know that’s the only time they have you by the balls. For the rest of their careers they’ll have to take orders from doctors. Sometimes, they’ll even have to fulfill those orders. Some of them have a pool to see how long they can ignore students who are asking, “Excuse me, can you help me find something?”
Half MD: I’m still not quite clear what my role is as a medical student. I finished general surgery last week and began the specialty service this week. Every week I learn of some new role such as getting X-rays from an unknown radiology location, changing the wound dressing according to the whims of a particular attending who uses methods that may or may not be evidence-based, or what information is supposed to written in the progress note. At times I feel like I’m in the movie Office Space. I have 8 bosses giving me orders at any one time.
Dean: The contradictory methods of leadership or the read-my-mind mentality that many attendings have comes with years of perfecting the art of frustrating students and residents.
Half MD: What’s up with pimping? I would guess that it’s supposed to be based on the Socratic method—using questions to lead a student towards discovering truth—but it’s really an embarrassing endeavor each morning when I can’t list 10 causes of a condition I’ve never heard of.
Dean: “Pimp” stands for “put me in my place.” Attendings can never be made to feel as if a student might be considered an equal in the eyes of others. Know the number 1 cause of a disease? I’ll ask you for the number 2 cause. If you know that information, I’ll ask you who authored the paper on the subject. If you’ve got that also, I’ll ask you the date that the article was published. I’ll keep asking you questions until you get something wrong and then smugly tell you that you need to study more. It’s all part of the learning process. Just wait until you’re an attending; you’ll get to treat students the same way.
Half MD: I keep getting the suspicion that many of the academic doctors aren’t cut out for private practice. Unfortunately, they aren’t cut out for teaching, either. If they’re so bad at teaching, why are they professors?
Dean: That’s a pretty harsh statement to make. The title of professor is reserved for anyone who holds a academic job. Some just haven’t learned that negative reinforcement is not a good learning tool.
Half MD: Any advice for surviving long on-call nights?
Dean: Try sleeping whenever you get a free moment. Empty conference rooms are perfect for catching an hour here or there. Don’t worry about sleeping through a page. The volume is intentionally loud enough so that you’ll wake up every time. It’s simple reminder that bad things happen to people at all hours of the night—and it’s your responsibility to fix it.
This post is just a quick plug for the Donut of Misery. Created by members of the military, the donut is used as a countdown to when deployment ends. I’ve modified it slightly to countdown the end of my surgery rotation. I’m already at the 50% mark.
As I was holding retractors one day this week, an awful fit of hunger hit me. I looked at the OR’s clock and realized that I hadn’t eaten in about 9 hours. I also realized that this operation was going to run another 2-3 hours and I would probably miss lunch again. In order to fight off the hunger, I propose that surgeons wear a camel back under their sterile gowns. Commonly used by long distance runners and hikers, a camel back is a back pack that contains water for the purpose of keeping hydrated on the go. A tube runs from the bag, over the wearer’s shoulder, and directly into his mouth. Whenever the runner wants a sip of water, he simply tilts his head toward the flexible straw, takes a drink, and keeps moving. In a similar fashion, surgeons could benefit from these devices during long procedures.
I could use a camel back to hold a can of soup to deliver it to me whenever I start to get hungry. I’ve got three whipples scheduled next week and I’m already thinking of ways to get fed during the surgeries. If I’m going to get varicose veins and hemorrhoids from standing for so long, at least I should be able to fight off the constant hunger pains.
To make matters worse, the bovie-the devices that melts human flesh and cauterizes wounds-makes everything smell like barbecue. A few of my readers might get turned off by the reference to cannibalism, but I call a smell like I sense it.
Perhaps my greatest frustration with surgery is that so many of the residents and students want to perform operations without ever thinking of the reasons why a particular procedure works, or why certain medications are used before and after major procedures. The chief cracks on internists by saying, “They’re only concerned about mechanisms of action and susceptibility.” What he doesn’t realize is that those mechanisms are extremely important. There’s a reason why diabetic patients take ACE inhibitors and not beta blockers. Unfortunately, our attending seems to follow the same line of thought and puts every patient on Reglan and prophylactic triple antibiotic therapy, meaning that all of those whipple patients now have super infections and are at risk for Parkinson’s disease. He could prevent the former problem from ever occurring if he would just wash his hands and use sterile gloves whenever he digs into a patient’s abdomen to look at the surgical site.
As part of the never ending line of assignments that I have to fulfill, I had to go to the residents’ lecture this week. The topic was on fluid management and reviewed all of the material that I had to learn last year as a 2nd year medical student. I was surprised as how elementary the material was. I was even more surprised during the review section when so many senior residents got questions wrong about basic electrolyte balance. It was like watching retards compete in the math Olympics.
Question: what will a high glucose level due to the patient’s sodium level?
Actual surgeon answer: if a person eats a lot of sugar, he must also eat a lot of salt. Therefore, it would be elevated.
Surgeons shouldn’t strive to be only knife jockeys. Anybody can cut stuff out of a patient. Even the scrub nurses have seen enough operations to know how to remove an appendix without causing too many complications. What makes surgeons unique is the “M.D.” after their names. If nothing else, they should at least know more about fluids and electrolytes than a fresh third year medical student.
Since my malignant attending has been out of town this week, his partner, an equally malignant surgeon has served as our attending. Rounding with him in the afternoons is a sight to behold. These trips are nicknamed “lightning rounds” because he runs through the patients so quickly. On Thursday, he saw 14 patients in four minutes. A typical encounter might go something to the effect of…
Attending: How are you feeling today?
Patient: Well doctor, I’ve got this pain…
Attending: change her dressing twice a day. What are her labs?
Me: (fumbling through the chart) Her creatinine value was…
Attending: Whatever. Who’s next?
The internal medicine crowd could learn something from him. I scrubbed in on a whipple he was performing earlier this week. He apparently hates teaching students as much as he hates talking to patients. I stood for four hours in total silence with my hands resting on the surgical tray. When time for class came around, I asked if I could leave early so that I could eat lunch before attending lecture. At that point, he finally acknowledged my presence by yelling at me that I should stay on the case until the moment class begins. Leaving early for lunch was “unacceptable.” I don’t know what good I was doing there at 2 in the afternoon if I wasn’t at least going to hold retractors.
Speaking of retractors, at least one of our attendings is eager to have student involvement during cases. I scrubbed into a total thyroidectomy with central neck dissection the following day. When the surgeon saw me enter the room, she immediately removed the mechanical retractor that was automatically holding open the patient’s neck, handed me two manual retractors, and made me keep the surgical site open. If you’ve never seen retractors, they look like shoe horns and serve the purpose of reminding everyone in the OR that the medical student is the surgeon’s bitch.
That procedure lasted nine hours. Imagine standing in place for an entire work day, not moving your arms, not eating, not peeing, and wondering when they’re going to sew this patient up so you can finally rest. The ophthalmologists are smart enough to perform all of their surgeries sitting down. No wonder getting into ophthalmology is so competitive. If other surgeons were that smart, maybe they’d realize that they don’t need to put every patient on Vancomycin prophylactically.
This particular case involved a rare type of cancer called medullary thyroid cancer. The procedure was going well enough until our non-paralyzed patient started moving during the surgery. Her thyroid was partially hanging out of her neck when she started jumping off of the bed. As I tried to hold her down, the surgeon went right on cutting as if nothing was happening. Later, my attending also hit the jugular and blood went airborne with a perfectly vertical leap. As Old Faithful shot forth, I jumped back to prevent getting showered in HIV and hepatitis. The surgeon replied, “Look at how scared this guy is.” Nice to be the bitch.
At least I finally got into the OR this week. I’m done with doing scutwork and cleaning up after my lazy interns who are here simply because they have to do surgical internships before running off to become radiologists. Next week, the screamer returns.
Dear Hispanic patients,
I am glad that you were so enthusiastic about the prospects of working in the United States that you illegally crossed the border to take the first available less-than-minimum wage job. However, would it have killed you to learn English? If I ever decide to move to another country, I would least want to study up on the local language and customs. Instead, when you’re sick, I can’t treat you without going through a translator. And when I tell you, “I don’t speak Spanish,” stop asking me questions in Spanish. And when I repeat myself by saying, “No hablo espanol,” don’t assume that I’m kidding just because I can at least pronounce the phrase properly. Yelling at me about your pain in another language is not going to get you treatment any faster.
Do you really need to put every patient on vancomycin, Zosyn, and fluconazole prophylactically? Only 4 of our patients have infections. The rest are clear of any disease. If your goal is to create a race of superbugs, you’re certainly on your way. Maybe if you washed your hands and used sterile gloves before inspecting a wound, we wouldn’t have to worry about infections to begin with.
The sign says CONTACT PRECAUTIONS. What that means is that you can’t touch the patient directly. In other words, contact precautions = hands off. Strangely, you felt the need to ignore the signs, the gowns conveniently left outside of the patient’s room, and the nurse standing in the corner with her death scare. You pulled up the patient’s gown, put your bare hands on the wound spot, and then asked me to remove his staples. Why didn’t you find it strange that I gowned up before going to work on his staples? I know we’re scratching our heads over why our lady with the whipple has a festering wound, but I think it might have something to do with your sticking your non-sterile, non-washed, gloved hand into her abdomen twice a day.
Anticoagulants and arterial lines are a bad combination. When I found my patient in the ICU bleeding out, I had to stick my finger in his radial artery to plug up the hole. Certainly you can understand my annoyance of sitting at the bedside with my finger in his artery for half an hour—especially since you had gone on break and knew that he had been bleeding earlier in the morning. Don’t tell me that I can cover it up with gauze and he’ll be just fine. How do you think he got in this situation to begin with?