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.
I’m sitting here at my desk looking at my old white coat. I’ve worn this jacket almost every day over the past year. It’s a reminder of the power and trust that physicians instantly hold with all patients. It’s the universal symbol of healing and knowledge. And yet when it comes right down to it, it is barely more than a glorified bed sheet with buttons and pockets.
It is covered with stains from various bodily fluids, food from the cafeteria, and a mysterious orange color that I have yet to identify. Although I’ve washed it regularly it will continue to be synonymous in my mind transference of infections from one patient to another.
This past year will certainly be memorable to me for a very long time. People talk about medicine as if it’s a calling. At no point have I ever felt as if God or any other deity was telling me to become a physician. But I do know that this is the field for me. Nothing else gets me up in the morning so early and so eager as medicine does.
Unfortunately, not everyone feels the same. So many of my classmates have gotten this far only to realize that they have made a very expensive mistake. I know of at least two people who now openly admit that they dislike medicine. Unfortunately, they are now more than $150,000 in debt and cannot leave the profession. They are now stuck in this job field for no other reason than economics. I think that many physicians are similarly trapped because so few other specialties have a high enough payout to clear the necessary debt that comes with this education. So to all of my pre-med readers out there: know what you’re getting into. This is an 80 hour a week job that comes with high emotional strain, abuse from attendings, abuse from patients, threats of litigation, inability to predict whether or not you will be paid, and a constant worry that maybe you didn’t make the right decision with that last patient. But if you like science, are good with people, and enjoy solving puzzles, then maybe you should consider a career in medicine.
Now that third year is over, I’m amazed by the amount of material that I have learned. I wonder why college took so long. If I were to employ the same model of education to my undergraduate degree that I have to med school, I would have earned my bachelors in about nine months. Despite all I have learned, I feel woefully unprepared to start practicing on my own. I started medical school with the realization that there was a gap in knowledge that needed to be filled before I could become a physician. With each rotation I see that there is no knowledge gap. It is a never ending abyss from which I don’t know if I can ever truly master. I have more training than a physician’s assistant, yet the medical community rightfully recognizes that I should not treat patients on my own. And despite similar realizations from physicians at all levels of training, the government and lobbying organizations continue to push for such asinine developments as “doctor of nurse practitioner.”
I look at this old white coat and realize that I have closed the chapter of one of the hardest years of my life. I look at it with a smile knowing that I don’t have to take a shelf exam ever again. I look at it with a frown knowing that one day my signature will be on the prescription pad or the order form—and that I’ll be the one who’s held accountable. I look at it and wonder where the last year has gone.
Prior to third year I used to exercise for a minimum of one hour a day. I was in such good shape that I had a resting heart rate of just over 50 beats per minute. The Air Force even recognized my athletic abilities when I was at officer training. And now, all that has gone away. When I was studying for STEP I, I gave up exercising so that I can free up more time to prepare for the exam. And then I continued not to work out. Due to the time constraints of this past year, I never got a chance to get back into shape. I also took the easy way out with regard to eating and began choosing fast food and microwavable meals over home cooking.
I tried running this week for the first time in almost 14 months. Once I hit the road I knew in less than 20 minutes at the past year has not been good to me. I gained 10 pounds since the start of third year—which is remarkable given that I’ve weighed the same for the previous decade. I started using a new notch on my belt, my blood pressure has risen by almost 20 points, my resting heart rate is up by 30 beats per minute, and there’s no telling where my cholesterol has gone.
I look at this old white coat knowing that I’m going to have to throw it away. It has simply become too filthy with all of the stains I’ve picked up here to continue its usefulness. And yet I hesitate to throw it away. I feel like there should be some kind of ceremony. A funeral. Simply tossing it into the garbage would be akin to shooting a member of the family in the backyard who has outlived his usefulness. And so there it continues to hang by the door where it has greeted me every morning over the previous year.
I look at this old white coat knowing that my training is almost finished. I look at this old white coat and know that I am about to embark upon the next journey—whether it be as a flight surgeon or in some other specialty. And whether medicine is a calling or simply an interesting job, I look at this old white coat knowing that one day soon I’m going to be a doctor.
A few months ago I wrote a post about psychiatrists’ being fake doctors. I stated that their inability to manage diabetes and hypertension disqualifies them from using the term “physician.” Today, I would like to extend that similar reasoning to the obstetrician/gynecologist: the ob/gyns are fake surgeons.
All throughout medical school ob/gyns promote their specialty by saying, “We practice both medicine and surgery. We see patients from across the lifespan. Praise us because of our vast repertoire of knowledge.” Things simply don’t work like that.
One immediate example is the multitude of second-year and third-year residents who are unable to tie suture knots. The ability to properly place sutures (“stitches,” as they’re called outside of medicine) is a skill that every doctor needs to acquire before graduating medical school. Certainly, I would expect all surgeons to be able to tie knots and appropriately perform simple surgical techniques. However, I have seen residents who time and time again must be re-taught methods of one-hand and two-hand knot tying. During many of these operations once the attending leaves, the third-year medical student takes over and finishes closing the patient. That perfect line on your belly from your C-section? That was me.
I’ve seen simple surgery such as laparoscopic hysterectomies take many hours solely because the attending in charge does not know how to use the equipment. If you’ve ever seen the bariatric surgeries on television, you’ve noticed that the surgeons hold one instrument in each hand to perform the operation. They then control the movement of the instruments using only fine finger motions. My own attendings are so inexperienced that they grasp the entire instrument with one hand to prop it up, and then use the other hand to manipulate its movement. The result is a need for additional hands (additional surgeons), wasted effort leading to fatigue, and an almost doubling in the amount of time necessary to complete the operation. In one particular case I was extremely annoyed when the attending tried to teach me anatomy by turning around the camera within the patient’s abdomen so that she could point out the liver and gallbladder. Well holy shit, lady! I would’ve never been able to figure out where the liver and gallbladder are. Thank you for halting the operation, singling me out as a medical student, and then showing me such basic anatomy as far as where the liver and gallbladder are. All of that time on my general surgery rotation I had imagined that those organs were within the legs. Thanks for correcting my ignorance.
Due to the need for additional hands (more residents), these cases get so overcrowded that the students take no part. When I did surgery, students typically held retractors and a conversation flowed with the attendings. Now, I don’t touch anything, I can’t see anything, and on several occasions I have had to completely step away from the surgical field because of all of the bodies pressing around the patient.
Perhaps the most annoying comment is the one about treating patients from across the lifespan. Given that they only see women who are of either childbearing age or postmenopausal, I would say that they have a very small subset of the population. Further, their lack of medical knowledge is astounding. For a specialty that promotes itself as performing both medicine and surgery, I would expect them to better able to manage hospitalized patients. When asked on rounds how to work up a patient with tachycardia (a fast heartbeat), my resident replied, “Consult with internal medicine.” His name was instantly added to the growing list of physicians that I would never let my family visit.
I was browsing through the Air Force’s website for graduate medical education today when I came across a letter from Colonel Hall, the director of physician education. She states that the selection rate for medical students is as high as 75%. What that means is that 1/4 of fourth-year medical students applying to residency will not match. That’s a pretty disheartening statistic to read, especially given that more than 94% of applicants match through the civilian route. I remember being a na‹ve pre-med who bought into the lies told by recruiters that 98% of medical students enter the specialty of their dreams. If I had known then that I’m about to spend several years as a general practitioner, I never would have accepted the scholarship.
Even more disheartening is that this chief does not seem to know how competitive certain Air Force specialties are compared to their civilian counterparts. She writes, “The more competitive or popular specialties such as Anesthesiology, Radiology, Emergency Medicine, and the Surgical sub-specialties have a higher non-selection rate than some of the Primary Care specialties- paralleling the outcomes in the civilian match through the National Residency Match Program (NRMP).” Anesthesiology and emergency medicine are competitive in the civilian world? According to the data published by the AAMC, anesthesiology and EM are only moderately competitive at best. With greater than 90% match rates in both specialties, the average medical student certainly has a shot at getting into these fields.
Christ, why did I ever sign up for this?
Update: you can’t watch television or a movie these days without seeing some high school student boasting to his parents that he can get a free college ride by enlisting in the military. Historically, the Montgomery G.I. Bill has provided educational benefits to veterans in return for their service. Currently, the G.I. requires a buy-in of $100 per month for the first year of service only to provide a little over $1000 monthly in educational benefits after leaving the military. Other than community colleges and a small number of state universities, few places offer annual tuition costs at less than $14,000. Even then, the money does not cover all of the necessary living expenses, books, and equipment that is incurred as the reality of obtaining a college degree. Recently, Senator James Webb of Virginia has introduced legislation which would guarantee four years of tuition at most expensive public schools in addition to living expenses. His reasoning is that the current G.I. bill needs to be overhauled to perform its stated mission. His bill cleared through the Senate with a 75 to 22 bipartisan vote. But guess who is opposed to this legislation: Bush II and Bush III. And I thought medical students had it bad.
Few professions can be as economically wasteful as medicine. Sure, we all love to bitch about politicians, but medicine really should take the award for financial pissing. We build wonderful technologies that can look at the inside of a person’s heart, check the electrical activity of the brain, read any component in a person’s blood, and even watch a baby move inside of the womb. However, all of these devices are made unnecessarily expensive by using non-standardized equipment and are being produced as new models that do nothing to bring down the cost of older versions.
Let’s take a look at the EKG. Any complaints of chest pain or a sensation like the heart is about to leap out of the chest will instantly be met with the EKG. This machine records the electrical activity through the heart and can be used in the diagnosis of arrhythmias, heart attacks, enlarge areas of the heart, and even certain electrolyte deficiencies. At its core, this device is simply comprised of 10 wires that are connected to an oscilloscope (a fancy voltmeter that you probably saw in college physics). I did some searching online and found that an oscilloscope can be had for about $150. The rest of the equipment needed to build an EKG can be found at Radio Shack for pocket change. In the real world, purchasing a new EKG machine runs about $2,000. What’s worse, this device will only print out the tracings of the heart as a snapshot. Getting a machine that uses a screen to show real-time activity of the heart cost even more. Then, once you have this paper-based tracing, you’ll have to insert it into the patient’s paper chart. The only way to get the same result into an electronic medical record is to buy a more expensive upgrade that can connect to a computer. Currently, the total package runs for about $4,500. The end result is that the physician will carry this charge to the patient for about $100 per EKG ($10 after insurance reimbursement). I imagine that an entrepreneur could build an EKG machine that connects directly into the computer’s USB port-complete with interpretation software-for less than $50. The computer’s monitor would serve as the oscilloscope; and a standard laser printer could print out the tracing on paper if desired.
Another unnecessarily expensive piece of medical equipment is the ultrasound. A solid high-resolution machine runs for almost $100,000. That’s a pretty hefty sum for a computer that merely interprets sound waves. One company has released a USB-based ultrasound probe that connects directly into the computer. According to press releases, it sells for just under $4,000. However, looking over these probes I’m concerned about the quality of the images. But the end result is the same: medical equipment can be produced at a cheap cost. The current system does nothing to reward us for developing innovative, cost-effective devices. Instead, we continue to throw away money on machines that can be produced by hobbyists for 1/100 of the cost.
Hospital nurses are the front line in any patient’s care. They provide his medications, they clean him, take him to the bathroom, feed him, and dutifully report the night’s events to the physician in charge. OB nurses will take this charge to the extreme. Their years of vast experience tell them that they shouldn’t let medical students or interns anywhere near a patient in labor. Despite my hospital’s policy that medical students should be involved in delivering all babies, the OB nurses will do all they can in their power to ensure that students are nowhere near the event.
For example, two sets of gowns and gloves are required for the delivery—one for the resident and one for the medical student. Medical students are supposed to be involved with every delivery in the hospital. The nurses know this, yet will passive aggressively prevent students from taking part. They will bring only one set of gown and gloves to the patient’s room, and when asked for another set by the resident, they will ignore this request and force the medical student to go on a hapless journey around the labor floor trying to find supplies. In my own case, by the time I got all the necessary equipment together and returned to the room, the patient had already delivered the baby.
The attendings are well aware of this problem. Despite multiple pleas from hospital administration, nurses continue to block medical students at every pass. This weekend was my last day on the labor and delivery rotation. Since I had not delivered a baby by myself yet, my attending told me that I would not be allowed to leave the hospital until I had caught at least one child.
My attending walked me to every nurse on the floor, introduced me, and said, “He’s going to deliver this patient’s baby tonight. Make sure that he has everything ready.” Expecting the nurses to once again have the room prepared for only the resident and not me, I preemptively went around and gathered all the necessary equipment and hid it in the patient’s room so that I would have everything laid out.
At 1:00 a.m., our patient decided to deliver. I threw on my equipment, got between her legs, and prepared to catch the baby as it made its way through the birth canal. The media portrays birthing as the miracle of life. An expectant mother has waited dutifully for nine months for the chance to see her baby breathe its first breath. In the movies, the baby always comes out perfectly clean and very beautiful. In reality, newborn babies look like aliens that are covered in fluid and shit and are very slippery.
The baby I caught came out in just one push. During the entire ordeal the father was holding his wife’s hand and telling her that everything was going smoothly. Meanwhile, I’m pulling out the baby and thinking to myself, oh shit! Oh shit! Oh shit! Don’t drop it! Don’t drop it! Don’t drop it!
I managed to hold on to this slippery creature, cut its cord, and handed it over to the pediatrician. After taking care of the placenta, my resident said, “Great, you finally delivered a baby. Now you can go home.” And just think, she’s going to be there for another six hours delivering more children.
There are lots of things in the hospital to be afraid of: violent psychiatric patients who try to attack everyone who looks like their family, homeless patients who cough on you, OB nurses, and attendings who want to tell you about Jesus. Hospitals have a rightfully deserved reputation as a dangerous work environment. Despite all of these things to be afraid of, nothing will throw people into a fit greater than HIV.
Let’s be absolutely clear about the way that HIV is spread. Only a direct insertion of bodily fluids will cause this virus to gain entry. Examples include drug abusers’ sharing needles, unprotected sex, and blood transfusions. What will not cause a spread of the virus is the physical exam. Skin-on-skin contact such as listening to the heart and lungs cannot cause a transmission of HIV unless both the patient and the healthcare provider have open wounds. This concept is pretty easy to understand. Yet despite all of the research and education that goes into this disease, people-including health-care workers-are woefully ignorant about the subject in practice.
Earlier this week I had a nurse stop me during the middle of listening to a patient’s lungs and admonish me for not wearing proper protective equipment such as gloves. I just don’t understand where this fear comes from. Yes, I know that there is a stigma associated with AIDS, but I would expect at lease for a nurse to understand how difficult HIV is to transmit. Mentioning those three letters on one of the nursing floors in my hospital will instantly cause a panic. Staff will begin putting on gowns and masks as if they are expecting a chemical weapon attack. Despite all of the frenzy that a weakly communicable disease causes, many people still will not follow proper precautions in other instances. For example, if a patient has an MRSA infection-requiring contact isolation-many nurses and doctors will continue visiting the patient without wearing the proper gloves and gowns. These health-care providers will then gleefully move onto the next patient’s room and spread all manner of bacteria.
Because of the extremely high number of nosocomial infections in my hospital, management has created several protocols for handling infectious diseases. We have placed alcohol rubs inside of every patient’s room so that people can wash their hands before and after each patient encounter. And while I’m thankful for these devices, I think that we need to do more. First, let’s get rid of the white coat and necktie. Multiple studies over the past few years have indicated that white coats and ties easily transmit disease from patient to patient, so much so that England has banned white coats from clinical areas [1, 2]. Second, let’s force all health care providers to use alcohol swabs on their stethoscopes after every patient encounter . I carry a pocket full of alcohol pads everywhere I go. After each patient, I clean my stethoscope similarly to how I wash my hands. If you’ve never cleaned your stethoscope before, give it a try. You’ll be very surprised by the amount of dirt that comes off in just one pass of the alcohol pad. And stay way from those silver-containing diaphragm covers. The advertisements claimed that by using silver ions, these devices can kill bacteria. In reality, however, these covers are a greater source of infection than regular dirty old stethoscopes .
So there we have it. Evidence shows that white coats, neckties, stethoscopes, and artificial nails are a source of infectious disease transmission . My hospital requires medical students to wear white coats, wear neckties, carry stethoscopes with them at all times, and has no policy regarding artificial nails. And the result is that we do a pretty good job of infecting people with C. diff, MRSA, and Klebsiella. Maybe what we should be doing is telling everyone that all of our patients have HIV. That way, they’ll be sure to carefully protect themselves from any communicable diseases.