Third Year in a Nutshell

I wasn’t really looking forward to patient contact. Because we spent all of first and second year far removed from the clinical practice of medicine I paid lip service to the idea that something was lacking in our medical education but to tell the truth, we had a pretty good racket going. We made our own hours, had no responsibility to speak of except the relatively easy task of passing a test now and then, and it seemed at the time that we had always lived liked this and always would. First and second year of medical school are like an endless vacation once you get the hang of things, especially if you have worked at a real job before going to medical school. We had people slime into class in what looked like their pajamas and flip-flops. How tough could it be?

So other than a few tense moments early in first year when it seemed like the body of medical knowledge we were asked to review was terrifying and impossible to assimilate, I rather enjoyed the first two years of medical school and dreaded the inevitable start of third year. I pretended to be excited about it, and it was true that this was an important milestone towards actually getting done with medical school, but I’d be lying if I said I looked forward to what I knew would be a complete loss of freedom. We had six weeks off at the end of second year. I used almost five of them studying for Step 1, after which I took a deep breath, looked at the sun and stars for the last time, and tried to stretch my last week of vacation out as long as I could.

The first day of third year was orientation and included a tour of the hospital, that big mysterious building attached to the medical school which we seldom visited as it had nothing really to do with us. The usual paper-work and disclaimers were signed and by noon we were done and given instructions to page the Chief Resident of the services to which we were assigned. My rotation group was starting on Surgery and I was assigned to Vascular for the first month along with another person from our rotation group. We paged the Vascular Chief and hit our first snag. There was apparently no Vascular Chief Resident, just the attending and a couple of upper-level residents rotating through the service who were themselves just starting. We eventually got in touch with one of them who was post-call from his previous rotation and he seemed far from thrilled to hear from us.

“Just meet me on the seventh floor at five tomorrow morning,” he snarled into the phone.

“Ask him if we can do anything today,” suggested my classmate.

“Are you crazy?” I asked as I hung up the phone. “Tomorrow is going to suck, I can feel it. Might as well have one more easy day. I’m going home before somebody changes their mind.”

That’s third year in nutshell. Tomorrow is going to suck, just like today and the day after tomorrow. I think I knew this instinctively.

I went home, moped around the house all day, went to bed early, and five o’clock in the morning found me standing nervously at the nurse’s station on the seventh floor regretting my decision to go to medical school. On the first day of third year you are the most ignorant and purposeless person in the hospital. Everybody else has a job. Even the janitors have an enviable purpose while the newly-minted third-year medical student stands around impotently in his brand-new short white coat trying to stay out of everybody’s way.

We managed to track down our resident who was annoyed that we hadn’t started seeing patients. He threw the census sheet at me and told me to go see the first three patients on the list.

“What am I supposed to do?” I asked innocently. At this point I had only the vaguest notion what vascular surgery was and I had put off researching it ever since I got the schedule. I was too demoralized to study anything about it the night before so I really had no idea what kind of patients we would have.

The resident cursed and made a snide remark at my expense.

“Just go in and see how they’re doing. Jesus, don’t they teach you anything? Take down their dressings and we’ll check on them when we round.”

It was dark in the patient’s room, which was to be expected considering it was only a shade past five AM. I groped for the light switch which glowed at the head of the bed and gaped in the flickering lights at my very first honest-to-God patient as he dove under his sheets and cursed at me for waking him. Later, of course, I would come to realize that if we didn’t wake our patients at all hours and stick them for blood every morning they might come to think they were in a hotel and we would never get rid of them. On that particular morning however, I was mortified and embarrassed to be so rude.

“Um, how are you doing today?”

“Fine, go away.”

I considered beating a retreat but noticed his bandaged left foot sticking out from under the covers. The smell was incredibly bad, like road-kill on a smoldering Louisiana highway. Trying to breath out of my mouth I unwrapped the bandages to reveal a shriveled foot ending in five blackened, gangrenous talons.

“What do ya’ think, Doc?” he asked, “Are ya’ goin’ to cut ’em off?”

“Uh, that would be my guess, sir. Have you passed gas today?” I don’t think this was relevant but at orientation they had said that every surgical patient needed to be asked this so not having anything better to say, I thought I’d buy some time to collect my thoughts.

The rest of the exam pretty much followed that stellar beginning. I pretended to listen to his heart with my brand new stethoscope, pretended to listen to his complaints, and then excused myself to go see the next patient. The other two patients were pretty interchangeable with the first except one only had one leg and the other had gangrenous toes on both feet.

I was beginning to see a pattern, the first of many in my long medical education. Feet need blood or they die.

At about six AM the attending physician showed up and we fell into line behind him as he walked down the hall. He stopped at my first patient’s room and then he and the resident looked at me contemptuously and expectantly.

“Mr. Smith is a 45-year-old man with a history of poorly controlled diabetes and peripheral vascular disease,” I began.

“Never mind that crap,” snapped the attending, “Are his vitals stable and did he have a fever last night.”

I honestly didn’t know.

“Well, Student Doctor, don’t you think it would be nice to know a little bit about your patients before rounds?”

At which point I realized that this guy would probably have his ass kicked every day if he worked in any other place but an academic teaching hospital. This was another pattern I discovered that day, namely that medical schools select for assholes.

The rest of rounds were equally enjoyable. Finally the attending told me to “just shut up” and I followed in humiliated silence. My classmate didn’t do too much better.

“The first case is at eight. Do you think you two can find the OR or do I need to draw you a map?” The resident clearly enjoyed our suffering. I noticed that the attending wasn’t too thrilled with him either.

“Man. This sucks,” said my classmate as we scrambled to write our notes, “I can’t believe we have a month of this shit.”

“Two years, my friend, two years.” The excitement of being a third-year medical student had lasted about ten minutes.

Surgery was awful. I contaminated myself twice while gowning and had to repeat the whole procedure to amuse the scrub nurse while we waited for the attending. “Next time get your own gloves and drop them on the sterile field,” said the circulating nurse. I don’t work for medical students.”

“Stand here, hold this,” was about the extent of the conversation for the entire four hour procedure except when I was asked some piece of medical trivia, the answer to which I invariably did not know. After a while the attending even got tired of that. He was pretty friendly with the nurses but I could tell they knew their place. The procedure was incredibly dull after the initial thrill of seeing somebody’s leg flayed. Harvesting a vein is pretty meticulous work but there’s really not that much to see. I fought to stay awake.

The rest of the day passed slowly. I tried to hide in the back of noon conference to avoid having to answer questions. This never works and I only later discovered that if you sit in the first row you almost never get pimped. More surgery in the afternoon followed by a repeat of morning rounds where I knew almost as little about my patients as I had in the morning. We finally got out of there at around seven. I was thankful not to have “trauma call” which we had every sixth day for the entire two months of surgery.

You’re supposed to study on your own for the Shelf exams but this is really hard to do during most of third year. Eventually you learn to carry around a little pocket review book and study a little here and there as time permits. But studying after a fourteen hour day with nothing to look forward to but more of the same was not very appealing at the time. Studying during first and second year is easy because it’s your only job. During third and fourth year (and residency) you have to study on top of having an incredibly strenuous and oftentimes humiliating job.

Third year got better. But not much.