Poodle Circus and Other Things (Real Questions From Real Readers)

You seem a little less bitter about residency.  How are things going?

Fine, thanks for asking.  I haven’t had call in about five months and I am gradually starting to forget all about it.  Sleep deprivation has always been my biggest complaint about residency and now that I am getting regular sleep I am pleased to report that I am feeling much better most of the time.  We do not have call in Emergency Medicine and, what’s better, we have a predictable schedule with shifts and conferences clearly layed out.  Oh, I still get tired. Of course I do.  Conferences always seem to fall on a day off or when I am getting off of long night shift and we do in fact work pretty hard. I don’t think there will ever be a resident who isn’t tired most of the time except maybe one of those lazy bastards in Physical Medicine and Rehabilitation.

Not to mention that I feel a lot better about things now that I am actually training for my job.  This is not to say that off-service rotations are not important.  Of course they are.  It’s just that on many rotations the teaching is at a minimum while the work is at a maximum.  There is something to be said for requiring residents to “figure it out themselves” but, and if I’m going way out on a limb here I apologize, doesn’t that sort of defeat the purpose of education?  In other words, if every time I ask an attending a question she snarls and looks at me contemptuously for having the unmitigated gall to not be an expert in a field that I have been exposed to for one week compared to her having studied it for twenty years, well, what’s the point of the rotation?    Whether I can look it up myself is besides the point and my asking for information is not the same thing as being spoon-fed.  I realize that the crusty old-timers are going to snarl and opine that, after crawling to the hospital though snow and broken glass, they had absolutely no supervision and learned it all on their own so I apologize for not being such a fine specimen of prehistoric medical animal.

Medicine is one of the few professions where superior knowledge breeds hostility.  As a Marine infantryman, for example, we never castigated the new guys fresh out of the Infantry Training School for not knowing how we did things in the fleet.  Rule number one is to never bully your subordinates.  You have them at an unfair disadvantage, in the Marines its the Uniform Code of Military Justice, in residency it’s the reluctance of a resident to do anything other than suck it up for fear of being fired.   Either way it reflects poorly on a leader who doesn’t have the empathy to realize this.

Because of the nature of Emergency Medicine residency training we tend to work fairly closely with our attendings for the whole shift.  My program has exceptional attendings all of whom take the time to teach, taking into account of course that we are always extremely busy.  So now that I am being taught the profession instead of just being used as cheap labor to cover call, I naturally feel much better about things.

I assure you however that I occasionally get demoralized and some might even say depressed.  That also seems to be the nature of residency.  You can have a string of good days where you do everything right and feel like you have a pretty good grasp on things only to have a couple of bad shifts, or even a couple of bad patients, where you so obviously show your ignorance and unsuitability for the medical profession that you dread going in for the next shift.  I have had a few shifts like that this week and I am feeling kind of beat down, if you know what I mean.

This is why I laugh at all of the lay people who email me or post snarky comments accusing doctors of being arrogant or having some kind of God complex.  There may be some physicians who have it all figured out to the extent that they always know what to do and never make a mistake but I assure you this is not me and, from discussions with my friends, I am not the only resident who is often humbled by the limits of his knowledge and abilities.  Residency training breeds caution, not arrogance.  If you think your doctor is arrogant it may be because you are, yourself, something of a jackass and cannot handle the fact that patients are not customers, the doctor is not a clerk, and you are not always right. 

I think I want to go to medical school, how hard is it to apply and get accepted?

First you have to get the basics in order which are getting good grades and scoring well on the MCAT.  I don’t have too much advice for that except if you are not incredibly intelligent this is going to require a lot of hard studying in college.  Medical school is pretty competitive and only about half of the college students who apply are accepted.  This might not seem like bad odds at first but you also have to realize that a large number of college freshmen who declare themselves as pre-med discover that they don’t have the right stuff and end up pursuing other careers.  So your odds are pretty good (and I call fifty percent good odds) only once you get through all of the obstacles which include classes like calculus and organic chemistry, the de facto destroyers of medical school dreams at most universities.

It’s not that these classes are incredibly hard, it’s just that the competitiveness of medical school requires that those who make the final cut, the twenty thousand students who matriculate every year, get exceptionally good grades.  When I was working towards my engineering degree, I worked hard but didn’t flinch at a B or even the occasional C.  These are both passing grades and nobody ever asked me about my Grade Point Average when I was applying for engineering jobs.  And there was certainly no GPA requirment for professional licensing as an engineer.  All that was required to sit for the Professional Engineeing Licensing Exam (a test that makes the MCAT look like a pop quiz) was a degree and five years of engineering experience.

But applying for medical school?  You need to get an A most of the time in most of your classes.  Maybe there’s no substantive difference between a 3.7 and a 4.0 GPA but there is a huge difference from an admissions point of view between a 3.2 and a 3.7.  One is an automatic rejection at many medical schools, meaning that your application is automatically shunted into the trash, or at least a big strike against you unless you have an awfully interesting resume (which is how I managed to get in with my GPA).  You definitely have to get very high grades in the BPCM (Biology, Physics, Chemistry, and Math) pre-requisites to even be considered.

The ironic thing is that all you really need to start medical school is the abiity to read and some basic, and I mean basic, biological and scientific knowledge.  In the first couple of days of medical school, for example, you are probably going to cover the equivalent of college semester’s worth of the subject.  You have to understand that college courses, compared to medical school, proceed at a leisurely pace and you will laugh to think that you ever felt college courses to be overwhelming.   The real purpose of the pre-requisuites is not so much to teach you anything but to demonstrate that you have the ability to handle the barrage of material heading your way.  Intelligence aside, if you can’t muster the discipline to do well in college, while you may be able to switch gears in medical school, the conventional wisdom is that you are not worth the risk, especially not when every medical school can find plenty of people who have shown that they can.

I understand that there was once a time when medical school admission was much easier but many matriculants were weeded out in the first couple of years.  As my old professors used to relate, the standard speech to incoming first-years was, “Look to your left…now look to your right.  This time next year both of those people might not be here.”  Now most of the weeding out is accomplished before matriculation and unless you lose that fire, that interest in the profession that keeps even the most jaded medical student slogging through, your chances of not graduating are vanishingly small.  In my class of 100, when all was said and done, only two people didn’t finish.   Several were dropped back a year but they all eventually graduated.

So you see, the big hurdle is getting in, not finishing.  And there are a lot of other hoops to jump through which have nothing to do with grades and make the whole process seem something like a poodle circus.  For the record the requirement for good grades is not a hoop.  It is silly not to have some kind of objective standard of intelligence for people who want to enter what is a highly important, intellectually demanding, and in many ways (as there is a great potential to harm people) a highly dangerous profession.  The real hoops are the nebuluous extracurricular activities that are unofficially offically required by almost every medical school to prove your dedication and your, I blush to call it, moral fitness for the job.

In other words, it is not enough to get good grades and have an inkling that you want to be a doctor because it is a useful, well-paying, interesting career with good job security but you must also prove to the admission committee that medicine is and has been your passion since the second grade and you view it as an almost divine calling to have the opportunity to help your fellow man blah blah blah.  Now, I don’t confess to kow the importance of extracurricular activities to medical school admission.  At some level the members of the admission committee must know that you only went to Zaire to help in a jungle hospital for resume padding.  Maybe American health care is not as advanced as Cuba’s but surely there are not long lines of American residency-trained physicians fighting for visas to practice medicine on the the Dark Continent, Central America, or anywhere else where a young medical school applicant may sojourn for a couple of weeks to demonstrate his commitment to global health care.

In the Pandaverse, if a young medical school applicant mentioned that he had volunteered in Chad the interviewer’s eyes would glaze over and he would ask, “So what does that have to do with practicing medicine in the United States?”  (Hint: Nothing.)

But whatever your feeling about relevance it is understood among the pre-med community that these kinds of activities are required and as the admission community endorses, either overtly or tacitly, this kind of thing you need to put on your frilled ballerina skirt, your ribbons, your muzzle, and jump…I said jump!…jump, poodle through the hoops and count yourself lucky that they haven’t yet lighted them on fire.  The way things are going, it is only a matter of time before an actual medical degree from a Third World country will be a requirement for admission.  Either that or having been intimately involved in the crafting of health care policy for some Brie-eating United Nations Bureaucrat.

Until that day you can probably get by with passing out clean needles to addicts, holding women’s hands at Planned Parenthood while they abort their babies, fetching water for the patients in the Emergency Department, or half a hundred other things that really make no difference and have nothing to do with the practice of medicine.  For my money, the most valuable things you can do are to either shadow a doctor or a resident (to give you a real idea of what is involved) or to get some kind of minor career in the health care industry where you can see if you have the stomach for it.  If you already have such a career then your’re golden because being a Paramedic or a Physical Therapist (for example) speaks for itself about your dedication. 

Research is probably the one thing you can do that will really set you apart from the pack.  Everybody passes out needles.  Hell, there’s nothing to it.  No commitement at all and the self-righteousness you can experience passing out the implements of self-destruction to people who may as well be alien life-forms to you for all you have in common with them is an added bonus.  You also get to practice your faux empathy and it gives you a chance to hate on President Bush for not making Heroin legal.  But the discipline to work for a cantankerous professor, essentially as his bitch, doing his grunt work to have your name on a paper?  That’s what I’m talking about.  It’s difficult and everybody knows it which is why meaningful research as an undergraduate will give your otherwise decent but not spectacular application a boost.

Short of that it’s going to come down to good grades and bogus extracurricular activities of the High School Musical variety, long on talk, short on action, in which you demonstrated some ethereal and hard-to-explain leadership traits.

Any kinds of patients you don’t like?

Naw, I like ’em all for one reason or another.  The sicker the better.  And I don’t dislike minor complaints either except that sometimes a minor complaint turns into a life-threatening emergency.  Nothing wrong with that actually except if I pick up the chart at the end of a shift.  But the minor complaints, the non-emergent, non-urgent, and sometimes puzzling patients (why on earth did they haul their kids and themselves out of bed at 2AM for a minor cough?) are a large portion of the bread and butter of our specialty and pay the bills, so to speak, that allow us hang around to take care of the two or three patients a shift who are either heading south fast or have arrived and are setting up camp.

(Public Service Announcement: Don’t skip dialysis over the Thanksgiving holiday so you can visit from out of town and eat highly salted holiday foods with your relatives.  I’m just saying…)

But there are, so far, two kinds of patients that annoy me a little.  The first are the drug seekers and frequent fliers who want to jump to the goodies and then get irate if I insist on a history, a physical exam, an assesment, and a plan.  Generally, I am not buying that on each of the thirty times you have presented for your back pain they just gave you some demerol and you were in and out in twenty minutes. 

Lady, the only people who get in and out of here in twenty minutes are the ones heading to the cath lab or the morgue. 

Not to mention that I don’t like being told how I am going to do my job by an amateur (although admittedly an interested one).  I happen to like trying the basic but effective things to break a migraine and 200 milligrams of Demerol is not on the “first do this” list.  I don’t even mind the lies.  Just don’t tell me what to do.  I have the medical degree.  It’s not much but it’s all I’ve got.  

The other kind of patient who annoy me are the ones who are ridiculously impatient.  Now, I understand that a visit to the Emergency Department, particularly a busy one that trains residents, can involve many hours of just sitting around waiting.   The beds are not comfortable and neither are the chairs for the family.  But can’t they get the sense, just by looking around, that we are sometimes insanely busy?  There are not that many doctors. If a trauma or two or a critical patient comes in that’s it for their minor complaint until things settle down again.  I am glad the minor complaints come in, the hospital and the law certainly encourage this kind of thing, but the Emergency Department only functions as your Urgent Care Clinic if there is nobody ahead of you who is sicker.  It’s not first come first served and I sometimes am embarrassed to have to explain it to people.  I apologize for the delay when I finally get around to them because most of my patients are decent people and very understanding but to the minority who are not, if you don’t want to risk the wait then don’t come in with your bogus complaint.  You said you had a problem.  You came to the Emergency Department at 2AM because it couldn’t wait until morning or for an appointment with your own doctor. Consequently, there is a huge prejudice on my part to give you the benefit of the doubt and do a reasonable amount of diagnostic testing and cognitive interpretation. 

Which takes time.  Time for the labs.  Time for the studies.  Hell, time for me to get around to writing up your discharge.  I generally want to get you out as much as you want to go so I can put you in the “win” column but not at the expense of giving you shoddy care.   Don’t keep bugging your nurse.  I have currently and will have in the future a huge incentive to get a disposition on you as fast as possible but a critical patient takes precedence and needs most of my attention until things settle out. 

17 thoughts on “Poodle Circus and Other Things (Real Questions From Real Readers)

  1. Love this post! After the shift that just ended this hit home and made me smile. Wish I could have printed this out and given it to a few patients today. Great writing as usual. Thanks!

  2. One thing i would suggest to potential medical school applicants is this- don’t apply to medical school if you ever had to study in college. It’s not worth it.

    I never did and I find medical school to be a demoralizing grind (MSII). The studying required is simply ridiculous… sitting down memorizing tables of pathologies for diseases we’ll probably never see in our careers is so frustrating and brainless- it sometimes makes me wish I never left engineering.

    I get pretty damn good grades and yet I know plenty of people who study 2x as much as I do and barely pass each class. How they deal with that kind of stress is beyond me.

    If you think ochem, biochem, or physics is hard then you’re in for one hell of a ride in medical school. Not that any of these subjects are terribly relevant, but the pace of learning in medical school is just insane.

    Absolutely love your blog.

  3. Another comment about applying to medical school. Some people have a knack for doing well on standardized exams like the SAT and ACT (and the MCAT), while others don’t have this skill. This does not necessarily seem to be related to how intelligent a person actually is. If you are smart and have good test-taking skills, you will have no problem getting into medical school and will have no problem passing through the first 2 years of medical school and the board exams. If you smart but aren’t a good test-taker though, be prepared for a tough road.

  4. I have to disagree with anonymo. I am also a second year med student, and have to say that these past two years – while not easy – have been the most relaxing ones since high school. I think Panda wrote an entry about the didactic years of medical school and the level of stress/work compared to that of a “real job.” (Pre-clinical) med school classes are, on average, much less of a committment than either of my past two jobs (engineering and high school teacher). Sure, you have plenty of studying to do but there are some huge payoffs: your time is almost entirely your own (unless you’re in a PBL-based program, in which case I pity you). Also, you really only have to concern yourself with your yourself. In a real job, you may have to worry about about your group or team or set of clients – people who’s wills you can’t directly control. In med school, you have to worry about learning for yourself, which is something most of us got the hang of back in high school or college, provided you made it into med school. Even undergrad was more stressful, as you had to busy yourself with extracurriculars and the potential anxiety surrounding the notion that you might not get into med school, or at least one of your choosing. As PB said, the hardest part is getting in. Personally, I’m in no hurry to “grow up” or to start my residency.

    (Amen.  If you decide to eschew lectures (a viable choice because most lectures are poorly presented) and study on your own, compared to working at a real job the first two years of medical school are like a vacation, albiet one punctuated with occasional high-stress exams.  Not meaning to slight anyone but the level of stress of first and second year students seems to be inversely proportional to their past work experience.  That’s why third year blew chunks for me, namely because I had never been so truly and completely somebody else’s bitch.  Now, of course, as a a resident I am used to it. 

    But first and second year?  Cracker please.  You can make your own hours, study whenever you want, and since most medical students don’t work, you can totally blow off the usual adult responsibilities.  -PB)

  5. Call me an ignorant 1st year medical student, but I already found in my few months here that while there are some very intelligent people in my class, the VAST majority are still just the type A overachieving study-till-you-drop students they have been their whole life, with maybe an intelligence level SLIGHTLY above the average college student.

    Anonymo, first year is stressful but even I find myself realizing how nice it is to wake up and know I have no REAL obligations.

  6. >> doesn’t that sort of defeat the purpose of education?

    Yes it does, but don’t think for a moment that residency and medical school are put in place to train doctors. If they were, an MD would take 3 years or less and residency would be much shorter. Really, how much time does a physician need to read through all of Harrison’s and grasp the navigation of UpToDate?

    About the medical extracurriculars you mentioned: while the minor careers such as EMT or CNA are certainly more valuable, they are often ignored by admissions committees because they aren’t volunteer positions. I had trouble explaining to universities why I didn’t hand out lolly pops at the VA when other applicants did. One admissions officer seemed annoyed that I would claim my experience in nursing as being superior to being a candy striper.

  7. Worst kind of patient in the ER:

    -The patient who has an immediate family member who is some type of “ologist”, and particularly if they are an “ologist” that deals with an organ system unrelated to the patients problem that has not required them to step into an emergency room themselves for 15 years. Which BTW are often the type AAA personality types of medical school that felt uncomfortable with the fact that they did not and could not know everything so they became specialists in the left lobe of the thyroid gland so they could be secure about something.

  8. I have to disagree with some of the previous posts, to an extent. I would say that getting into medical school is NOT the hardest part. It was tricky enough, all right, but it got harder after I got in. I’d also strongly disagree with anonymo. I definitely studied in college, often a fair amount. I did pretty well, and I’m doing fairly well in my M2 year as well. I study more now, but it’s not at all true that most of my classmates didn’t study in undergrad. Some of them just absorb information like sponges and don’t study much, but they are the minority.

    Also, some aspects of the first two years are still quite difficult. Is it nice to set your own schedule? Absolutely! I’ve worked several thousand hours in landscaping, and it can be a terrible thing to show up there every single day at the same time for the same duration, but on the other hand, when I leave my job there, I forget everything about it. Med school follows me wherever I go. Also, there’s something to be said for accomplishing something and getting paid for it. I often liked making someone’s property look beautiful and getting paid to do so. Med school usually just reminds me that I’m not as smart as I’d like to be, and by the way, that’ll be $30,000 for your troubles.

    I agree with PG – undergrad was certainly busier, what with research, volunteering, work an all – but maybe it’s just me, studying all the time can be quite draining. My brain juice just runs out sometimes.

    Lastly, how can anyone go to lecture? That would take up SO much time!

  9. Patient’s perspective – waiting for a (relatively) minor complaint, (especially if your put in a room in an out of the way location and can’t see what else is going on) is a whole lot more bearable when somebody (nurse, or the doc, or whomever) comes in occasionally to check on you and let you know that a big MI came in or there were two car accidents, or the we sent your blood to the lab and are waiting for the results. Communication is a very good thing! Without that, the patient’s mind will of course wander to thoughts that they are being ignored or have been forgotten. A wee bit of honest, genuine communication goes a long way, and is just as, if not more important, as the doc’s bedside manner when they are in the room.

  10. I go to lecture. But we only have lecture for 2 hours a day, so it doesn’t take up much time. I can’t imagine being at a school that makes you sit in lecture 8-5 or so. I find I’m more efficient if I got to my 2 hours of lecture – but if I had more I’m sure I’d skip to study on my own. But I’m out by noon and as I have to be in small group from 8-10 anyway, I figure I might as well go to formal lecture since I’m already at school.

  11. I also went to medical school as a second career. I had to commute 80 miles one way to the main campus the first two years. But I disagree about the benefits of not going to class. I tried to attend all of the lectures. I bought my board review books and highlighted and took lecture notes in the margins. I also bought the lecture tapes and listened to them again on a variable replay speed tape recorder on the way to and from campus. As a consequence, I did not have to study much or at all for the tests. I still read the textbooks for deeper understanding, but if you sit in the class and get a feel for the teaching style of the prof, you absolutely know what is going to be on the tests. Also, all of the medical schools have a vested interest in having their students pass boards, so all the stuff on the test will be in the board review books. I just thought of it as an 8 to 5 job. Definitely easier than working.

  12. Well, see, lecture tapes are a thing of the past now. My medical school records the lectures and posts them online within 2 hours of the lecture itself, usually far less. There are notes, powerpoints, mp3s, and the .avi (movie) files of the lectures, with notes and powerpoints usually provided before a few days before the lecture. Most professors speak so slow you can watch the lecture on 1.5x speed. Additionally they’ve provided the lecturers with one of those “sportscaster” style pens where they can write on the powerpoints as they are giving the lecture if they need to emphasize a point or draw to explain the answer to a question.

    But not everyone can absorb information in lecture. Last year I hardly went to class and for me this was a good use of time. This year I find lecture more useful so I go most of the time. It depends on the subject material, the lecturer, and the individual learning style of each student.

  13. Dear Random MSII,

    I clearly got the short end of the straw by winding up at one of those 8-5-type schools, and cordially hate you. They haven’t mastered the idea that filling up all day with lecture means an impossibly small amount of time to absorb it.

    On the other hand, basic sciences are still as useless as ever when taught by professors who just don’t have a knack for presenting material in a better way than the textbook, which at least had to pass some kind of editorial and pretty-pictures committee.

    So, yes, I add myself to the carefree lecture skippers, with the caveat that there’s one thing you ALWAYS miss when you quit a job for school: the money. My piddly salary wasn’t much but you sure miss it when the money’s flowing out instead of in.

  14. First and second year were the most miserable time of my life. There is always more that could be done. You never get the relief of letting anything go. Every time you want to do something, the “you should be studying” monster is whispering in the back of your brain.

  15. KS, no worries, I would hate me too if I hadn’t opted for this school. And yes, I really miss my salary. I worked in preclinical toxicology for 2.5 years before going back to school. I was in the “working world” for less time than I was in college but man, its nuts how quickly you get used to being a regular adult and being able to do things like spend money. I still spend money, but now it’s at 6.8% interest. 🙁

    And Phil, I’m with you. I hate the monster. He ruins my life.

  16. Just wanted to throw in an MS4s perspective, on my way out of med school. Undergrad years were the best of my life, retrospectively. I was coming out of 4 years active duty as an Infantryman as well, so when I was not suppressing the urge to rip the throats out of whiny college brats, I was out fishing or hiking, not studying. My pre-reqs were ridiculously easy, and I graduated with a 3.8 and walked right into med school. Then it began to suck.
    I crawled through MS1 and MS2 barely passing each class. I passed all my classes and passed Step 1 by the skin of my teeth. Nothing is as bad as the nagging feeling that while you are eating dinner or playing trucks and blocks with your kid, everyone else in your class is furiously cramming for whatever exam-du-jour is coming up tomorrow. I hated that feeling, and every day I rejoice that I’ll never have to feel it again.
    Then 3rd year came, and I learned new definitions of the word suck. I also learned how truly evil your fellow med students can be when they are dead-set on a competitive residency and feel that they need to make you look like shit to further themselves. I opted out of that BS and freely admitted to attendings, residents, and med students alike that I was a lazy bastard who wasn’t ashamed to place his family ahead of his career. Needless to say, my evaluations reflected this.
    So here I am at the end (almost) of 4th year. I’ll match for sure, (into a non-competitive primary care field) and it’ll be 3 more years of sucking during residency till I’m done and can find a job that allows me some semblance of a normal life.
    And yeah, I am scared shitless at this point about my massive student loans, how much call I’ll be doing, a shitty primary care salary, and the impending Clinton administration massacre of the what’s left of American heath care.


    (Fucking-A, buddy. Hang in there.-PB)

  17. I haven’t been to lecture since October 2006 (currently MS2) and right now, I am sitting on my bed, waiting for the videotaped lecture from 9 AM today to load on my computer. I will watch the 50 minute lecture in about 35 minutes thanks to a program that allows me to speed up the video without audio distortion. This probably saves me about 30 minutes a day MINIMUM…plus, since most lecturers SUCK ASS and talk so slow anyway, I’m not missing a thing by speeding the lectures up.

    It is absolutely true though that there is no real mental break during these preclinical years. There is always something more to be studying. And if you’re so smart that you know it all (no one is), then you should get your brainy ass into the lab to do some research, or find someone in your field to shadow and learn from. Really, there’s no excuse to be bored or lazy in medical school. And the way I see it, I am paying a crapload of money to bascially teach myself from board review books, so I may as well leech knowledge from paid faculty and researchers at my institution while they are available to me.

Comments are closed.