Category Archives: Third Year

Don’t Tell the Spartans

(Many of you are about to start third year and are looking forward to it with feelings of both anticipation and dread. You know that it’s going to be the real start of your medical career where you finally get to see what all the fuss is about. At the same time, despite the propaganda, you have the uneasy feeling that third year is going to blow, and blow hard, not for the least of which reasons because, after what in years to come will have seemed like a two-year vacation, you now will be working on a rigid schedule with responsibilities that you can’t casually shirk.

There are two schools of thought about clinical education for medical students. One school believes that your clinical years should be a model for residency complete with long hours, pointless abuse, and call. This is under the theory that it will toughen you up for residency where you will be further toughened up so you can be prepared for the real world where medicine is not practiced at all how it is in residency.

The other school, the Panda School, knows that abuse serves no purpose other than self-justification for the past suffering of the abuser, that you cannot condition yourself to do without sleep, and that clinical training as it is currently structured at most medical schools is actually detrimental to education. Not to mention that since you will get plenty of abuse as an intern, there is no point wearing you out now, especially since, despite what The Man says, you have no responsibility for patients.

I was referred to an interesting discussion on the Student Doctor Network about the mistreatment of medical students by residents and since we have been giving short-shrift to this topic (although Brother Hoover has it covered pretty well) I thought I’d try to address some of the common complaints that medical students have about residents and particularly interns.

I am known to be very easy on medical students, by the way, as some of my medical students who read this blog can probably attest.-PB)

1. It’s my first day on the Service, and my first day of the third year, and the intern is mad that I don’t know anything.

I don’t know of another career where the trainees are berated for not knowing their job on the first day but this is a fact of life for medical students. On the first day you won’t even know how to work the phones much less care for patients and it may take you hours to complete a simple task (such as dictating a brief note) that you will complete in thirty seconds as a resident. This is because you have nothing but jumbled facts bouncing around your brain with no experience in marshalling them into a coherent assessment and plan for your patient. You also have no idea about the logistics of the hospital, where they keep things, and who does what.
I don’t know why this is hard for some residents to understand except that medical school admission committees seem to be selecting for assholes and, although medical school is good for personal growth, these people tend to grow as assholes.

The solution? There isn’t one except the general advice that the hospital is not Thermopylae, the patients are not the Persian hordes, and you are not a Spartan who has to sacrifice himself for the greater glory of a large, bureaucratic machine that if possible, thinks less of you than it does of the residents. Pace yourself. Realize that you don’t know anything, and revel in it. Don’t apologize, and be direct in the face of worthless, spiteful criticism, especially from an intern.

I assure you that interns have very little input into your grade for the rotation and generally speaking, as most residents are decent people, we can see as easily as you which interns are socially dysfunctional. You also have to ask yourself if your grade is more important than your self-respect. If it is, then you will have to suck it up. If not then you should establish the ground rules for how you are going to be treated early. As Dr. Phil says, we teach people how to treat us. If you are firm, forceful, and fair, people will either respect you or they will be intimidated, either one of which is fine. If you are a weak, squirrely biach you are going to be treated as such.

It’s like prison. If you pick a fight with the meanest, baddest prisoner on your first day, win or lose you are going to establish some credibility. I’m not advocating beating your intern but it’s not like this guy is that far removed from you. Hell, it’s July. He’s more scared than you because he has real responsibility. So sometimes, as you learn in the joint, a brother has to shiv’ a motherfucker. Establish early on that you are not a biach and you will do fine.

2. My intern is stealing my work and getting credit for it.

One of your duties will be to see patients and write notes, especially the time-consuming Admission History and Physical. No question about it, medical students write exhaustive H & Ps. You usually have the luxury of time while your intern is perptually under the gun so his may be a little more sparse than yours. While you may turn in a copy of your luxurious History and Physical for a grade, to your intern it is nothing but meaningless paperwork, especially since for 95 percent of patients everything pertinent could be written on a small index card in thick black marker. It’s another obstacle in a day filled with obstacles. He also knows that even in the unlikely event that anybody reads the note, the only thing they are interested in is the assessment and plan and not your detailed description of the patient’s travel history since the Carter administration.

Your intern does not get credit for your History and Physical. There is no such thing as “credit” for this sort of thing. It’s done, the box is checked, and it becomes just another scrap of paper mouldering away down in medical records. I have never heard an attending say, “Hey, that was a cracker-jack History and Physical. Take the rest of the day off.”
So don’t sweat it.

3. My intern is stupid.

Have a heart. You are fresh from two years of intensive lectures and the USMLE Step 1. Your intern spent most of the last six months of fourth year playing video games and catching up on sleep. I am a PGY-2 (second year resident). I once asked a medical student a question and when he went into his pimp-defense mode I said, “Relax, I’m really asking you if you have ever heard of this condition because I sure as hell don’t remember it.

Not to mention that your intern is sleep deprived and under a lot of pressure. It is easy to look and sound stupid if you’re supposed to know what’s going on but don’t which is typical of most interns. It’s not that they’re stupid, it’s just that compared to their upper levels and attendings they seem that way. They’re learning too, just like you but the difference is that they count and you don’t (no offense).

On the other hand since “MD” actually stands for “Minimal Doctor,” it is quite possible that your intern is, in fact, a jibbering moron, at least by medical standards. It is inevitable that somebody is going to slip through the cracks and the “questionable admission” may very well have pulled off yet another snow-job and landed a residency position. Not to mention that there are a few specialties that are known for scraping the bottom of the barrel when it comes to the help.

If he’s a jibbering motard but otherwise a nice fellow you might consider trying to cover his ass. You don’t have to, you understand, and nobody is going fault you or even know if you don’t but good residents look out for each other and you may as well start practicing now. I know, I know. You’ll be helping a guy along who will one day be in the position to hurt patients but decent people don’t think like this. Let his State Board sort it out.

4. My intern tries to get me to do his work, especially on call.

I despise call, probably more than most people. Ever since I started publishing this blog it seems like more and more residents are coming out of the closet in this regard. Certainly when I was a medical student to say you disliked anything about medicine, not just call, was viewed with the same horror by your residents as if you had a large, greasy bowel movement in their Lucky Charms. But they’re not fooling anyone. Call blows. Nobody likes it just like nobody really likes residency training for the most part except that some tolerate it better than others.

So it would be natural for an unscruplous intern to try to either shame you or force you into doing his work for him. Just keep two things in mind. First of all, most medical schools have rules about call for medical students. At some, medical students are to be discharged at some reasonable hour of the night because, wonderous to behold, the school realizes that a medical student’s purpose is to learn, not to be a scut ox who is too tired to study. It is up to you to know the rules and grow a set of gonads about sticking to them. Don’t care for the rotation or the intern? Hey, it’s eleven o’clock buddy and I am outta’ here! All you have to lose is the respect of the intern…but…and stop me if this is obvious…he’s just an intern. His respect his worthless anyways if it comes at the price of your sleep and your health. Stay all night if you want and if you feel like you will learn something but scut work is worthless and you’re not being paid to do it.

The second thing to remember is the French Hooker Rule. No matter what they want, you can only give them what you can give them. It is not your responsibility to clear out the backlog of admissions in the Emergency Department. Most interns wouldn’t even think of giving you this task, not for the least of which reasons that you can’t do it. But sometimes a lazy and unscrupulous intern, on being paged for an admission, will send his medical student to knock out the preliminaries which involves most of the paperwork. Learning is one thing and you need to do some admissions to get the feel for it but you are not cheap labor, the intern is…or didn’t he get the memo?

And I am sick of sports metaphors. It’s not a team. If it were a team everybody would get treated better than they do. It’s more like a salt mine (I mean if we’re going to throw metaphors around). Do your assigned work diligently but don’t be patsy either.

5. My intern berates me in front of the other students.

Berate back. He’s not your mother. There is no penalty for shoving back. You are not contractually obligated to take crap from anyone. On the other hand, no need to be on a hair-trigger, either. Certainly don’t buy into the “Welcome to My Service” speech that some interns like to give. I got one of those as an intern from my twenty-something third-year resident who, among other pearls of wisdom, informed me that my family needed to come second after medicine in my order of priorities. This only sounds good to people who don’t have families, of course. The point is that the intern has different priorities and goals for the rotation than you might have. It may be his specialty and he may be really into it. You may hate the specialty and just want to get through it with the low pass.

The irony of medical school is that you are expected to take abuse from people who are only a few years ahead of you in training and whose ass you would otherwise kick if they treated you half as bad anywhere but the hospital.

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 7

Family Medicine

(Some medical schools have a formal Family Medicine rotation while others have a regular continuity clinic that runs concurrently with your other rotations in third and fourth year. Osteopathic medical schools hit Family Medicine and primary care like a pimp with his biaches, that is, hard and often.-PB)

Your Real Responsibilities:

Nothing.  You’re a medical student  You don’t count.  When you first get started your continuity patients who have at last found someone to listen to their long and incredibly boring back-pain epics will get the kind of rush that made them become professional patients in the first place.  So if you have any responsibility, it is to put the teeth into your school’s empathy indoctrination.  Relish this time because it may be the last chance you have to fritter away forty-five minutes exploring every detail of a patient’s life like your non-physician empathy instructors told you to do.

Your Pretend Responsibilities:

If you rotate on an inpatient Family Medicine service, it will be pretty much what you did on your Medicine rotation except the census will be smaller and your patients will generally not be as sick.  Traditionally, Family Medicine only admits their clinic patients, not everybody who shows up like Medicine, so while the service is small, usually consisting of an attending an intern, and an upper-level or two, the pool of potential patients is even smaller.  This will probably be a pretty relaxed rotation as you will not be seeing many patients.

In clinic, you will pretend to evaluate patients who you will present to your attendings.  Eventually your attendings might start to trust you with the minor stuff (and there is a lot of minor stuff) so you may run the whole encounter with a brief social visit by the attending to verify that it is indeed a post-nasal drip and not a raging esophageal cancer.

Things You Should Learn:

Three words: Routine Health Maintenance.

Learn when your patients are due for their shots, their mammograms, or their screening colonoscopies and you will be the Golden Child, the Wunderkind who will bring unity to the primary care force.  Trust me.  You will finally get an interesting patient who looks like undiagnosed lupus and you will be on fire presenting this amazing discovery when your attending will interrupt to ask when she had her last pap smear.  Routine health maintenance is just one of those important defining features of Family Medicine.  It’s their niche and they live for that sort of thing, taking the same satisfaction in getting their patient’s medical house in order as I get in discharging a drug seeker without the narcotics he was looking for.

There are also a few common conditions that will account for almost all of what you see.  A medical student, for example, who understands diabetes, how to manage insulin regimens, and what oral hypoglycemics to prescribe (and why) will double-secret pinky honor the rotation.  If he understood Asthma, Hypertension, and COPD he will walk on water.  If he believes in Fibromyalgia they will proclaim him Family Medicine Material and the full court press will be on to keep the other, more lucrative specialties from seducing him with their promises of interesting work and high salaries.

Things that Will Suck:

The complaining.  Family medicine is a specialty in the midst of an identity crisis and the angst of being the lowest-paid and least respected specialty is going to come through, loud and clear.  Somewhere, the specialty took a wrong turn and decided that social work and many other non-medical functions were part of it’s purvue which has only added to the confusion.

The key problem is that the “Family” is not an organ system which can be treated medically. Since we treat individual patients and not groups, to treat the family, Family Practice physician need to be internists, pediatricians, and OB-Gyns at different times during the day. Since there is no way to roll these three unique specialties into a three year residency, many Family Physicians feel as if they have become nothing but clearing houses for referrals to specialists which can be demoralizing and explains the quest for job justification.

But other than that philosophical crap which you may or may not care about as you hope to become an ophthalmologist and be above those kinds of concerns, if you don’t like routine medical conditions and predictability you will intensely dislike your family medicine rotation.  It’s as simple as that.

Oh, and the grading for the rotation, if you worry about this kind of thing, is more subjective than usual.  The best student in your group will barely pass if he can’t conceal his distaste for the pace and concerns of the specialty.

Cool Things About the Rotation:

I think everybody likes to play doctor which is pretty much what you will do on the rotation.  Family Medicine is what most of you imagined medicine to be like, at least those of you who have not been anal compulsively pursuing a plastic surgery fellowship since the eighth grade, and the immediate risk to the patients is so low that you have the time (as a medical student, that is) to really get to know your patients.


Bogus, as usual, but since you will only do call if your hospital has an inpatient Family Medicine service, you might slide out of it.  Since the census is small and you are unlikely to be attending medical school where the Family Medicine residency program is unopposed, your duties on call will probably be light and the admissions will be infrequent and fairly straight-forward.  Many Family Medicine services, for example, do not admit and follow critical care patients.

You will certainly not take home call like the Family Practice residents who, in addition to their regular duties, have a panel of pregnant patients threatening to pop at any time.  The logistics of this would just be too complicated.

Slacking Potential:

Terrible.  Clinic goes all day and you will have to be there.  And it can be a slacker’s nightmare as you may have to shadow an attending leaving you with no opportunities for hiding and sliding.  Still, if it’s a clinic rotation it will be a nine-to-five sort of thing so I wouldn’t worry about it too much.

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 6

(Surgical specialties are usually grouped together in a one month block although they may do things differently at some schools-PB)

Surgical Specialties: Urology, Ophthalmology, Otolaryngology, and Orthopaedics

Your Real Responsibilities:
Nothing. You’re a medical student. You don’t count. And since you typically only spend a week on each service with the weekend off in between, you will matter even less than usual. You could get an inflatable sex doll, slap a short white coat on it, wheel it around on rounds, and nobody would notice a thing except maybe that the good looking chick in the back was unusually quiet for a medical student and didn’t ask nearly as many annoying questions.

Your Pretend Responsibilities:
Hardly any. Come on now. You’re on each service for a week. That’s hardly enough time to learn where they keep the paper-clips much less be of any use. If you subtract the time you spend in mandatory lectures or “Continuity Clinic”(if your school has this) your face time is even more limited and all you are really good for is getting in the way. If your residents don’t like to teach you will feel this keenly.

Things You Should Learn:
Urology: Common disorders of the male urogenital system. Impotence (or Erectile Dysfunction as it is called to avoid offending the impotent) is big. It’s the bread and butter (or potatoes and sausage if you will) of urology. Common presentation of urological malignancy like bladder cancer, testicular cancer, and the like. The prostate, of course. It’s huge. Probably deserves a blog of its own. Urge, stress, or overflow incontinence. Buzzwords: VCUG and TURP.

Otolaryngology: Anatomy of the head and neck. Dysphagia, odynophagia, and when to worry about them. Common malignancies. Otitis media gone horribly wrong. How to stand in the operating room doing nothing for eight hours pretending to be interested. Buzzwords: Uvulopalatopharyngoplasty. PET.

Orthopaedic Surgery: How to talk to an orthopaedic surgeon when you call him at 3AM. In other words, how to describe fractures and dislocations completely and succinctly. This would also be as good a time as any to review musculoskeletal anatomy. Simple casting and splinting and when to call a consult even if the xray of the wrist looks fine. Work on you upper body strength or stay out of the OR.

Ophthalmology: Common disorders of the eye. Glaucoma. Diabetic retinopathy. Macular degeneration. Now would be a good time to learn how to use that expensive ophthalmascope they made you buy. Recognizing ocular emergencies (retinal artery occlusion, detached retina, globe injury). Recognizing things that are not emergencies (hyphema, corneal abrasion).

Things That Will Suck
Not that much. It’s a pretty good month with no call (typically) and no pretenses that you are part of the team and thus no need to fake enthusiasm. Still, if by this time in your career you are sick of shadowing (following a doctor around and watching what he does) you are going to be unhappy as you will do a lot of this.

Urology clinic is painful. Call me a homophobe but I lost interest in holding some other guy’s wedding tackle after…let’s say…thirty seconds. For being a holder, Boy George had nothing on me that week. I also do not, repeat do not, want to hear seventy-year-old men telling me about their sex lives. Sorry. If I give you some Viagra will you shut up? I find discussions of how your penis broke particularly disturbing.

I’m not mature enough for urology.

As I mentioned, head and neck surgeries of the kind you might get sucked into unless you have your slacker game on can last for days. I made the mistake of scrubbing in on a facial reconstruction surgery that started at 8AM and ended at some unknown time after 4PM when I had to scrub out for a mandatory didactic activity. I have never been so happy to sit in a conference room talking about empathy.

Cool Things About the Rotation:
Not that much. I guess it depends on you level of interest. I had a friend who had always dreamed of being an orthopaedic surgeon and he had the time of his life. It was bearable, the hours weren’t that bad, and it’s mostly interesting stuff when you think about it. If you don’t like something, well, it’s really only five days. I can endure anything for five days. By the time you’ve had enough it’s Friday afternoon.

None, generally. And since you’re something of a cross between a migrant worker and a hobo, nobody really knows you and it will take a supreme effort of will for your resident to remember your name, even if he wanted to wake you up at 3AM. Ophthalmology and Urology are not “call heavy” specialties either so even if you did have call, you’d probably do less than the resident.

Slacking Potential:
Fantastic. Got some personal business to attend? Significant other coming to town? New game console? Sponge Bob marathon? For a slacker this is your month and it will have everything: Rapid turnover? (check). Busy residents? (check). Confusion? (check). In fact, you could probably not even show up and nobody would know or care. I am a resident. I usually don’t know my medical students unless they introduce themselves and say, “Hey, Dr. Bear, I’m Joe Schmuckatelli and I’m working with you this month.” Imagine if the medical students switched every week and some weeks there were no medical students at all. And how do I know if you don’t actually have lecture, for example. Hell, I don’t even know your name. If I even care and you gave me some vague excuse or another I still wouldn’t care.

Let’s just say that if you have just come off of six months of general surgery, OB-Gyn, and medicine this rotation will give you a much needed breather. My wife referred to my surgical specialty month as “that month when you were home a lot.”

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 5

(Some schools offer students the chance to rotate in the Emergency Department in third year while some only offer it as an elective in fourth year.-PB)

Emergency Medicine

Your Real Responsibilities:
Nothing. You’re a medical student. You don’t count. But that’s all right. We’re happy to have you. It’s true you’re not much help but you will pull a few charts from the inexhaustible supply and it’s not like you’re in our way or anything like that. And, unlike almost every other rotation, we won’t fill your day with mindless scut. Even if we did, you don’t have to go very far to do it. Not to mention that as a rule, Emergency Medicine Physicians are pretty easy-going and you will rarely find the type of malignant personality that is common on some other rotations.

Your Pretend Responsibilities:
Pretty much what we do, albeit at a slower pace. Grab a chart, evaluate the patient, formulate a plan and present it to your resident or attending. You don’t have to move the meat. If you see five patients in a ten hour shift and do a really thorough job that’s not bad.

Things You Should Learn:
1. How to be succinct. It is generally not necessary to do a medicine-type presentation for every patient but the surgery-type (“Patient looked OK from door”) is not enough either. As an example, you can spin a long story about how badly the patient’s chest hurt after he mowed his lawn and how it felt like he was being stabbed and how he got, like, all sweaty or nauseous and had to, like, sit down and rest.

Or you can just say, “Mr Smith had sharp, severe exertional chest pain with diaphoresis and nausea relieved by rest.” Learn medical language. Not only is it precise but it saves time.

Bad: “Mr. Smith was feeling nauseous last night and threw up all over himself several times since yesterday. He’s hasn’t been feeling well lately and has been coughing up green stuff. He can’t hold anything down now and hasn’t eaten anything in two days. He has a burning pain in the left, lower part of his abdomen which he won’t let me touch. In fact, his abdomen is rigid.

Better: “Mr. Smith has a one-day history of nausea, vomiting, malaise, and a cough productive of green sputum along with constant left lower quadrant burning pain and and guarding.”

Best: “Mr. Smith was hurling like my prom date and I think we need to call surgery.”

2. How to let go. Come on. You can do it. There comes a point in every Emergency Medicine relationship when it is time to let somebody else have your patient. Tentative diagnosis made, appropriate tests ordered, patient stabilized, and admitting service notified. It’s time to wave goodbye to your pride and joy and hope that you raised them right and they won’t forget what you taught them. Why, you knew them when they first came in and now they’re all stable and pain free.

It almost brings a tear to your eye.

3. How to joke around a little. It’s all right. Some of the patients are idiots. It’s Okay to laugh at their exploits. You don’t have to get all pissy at some of the nicknames the nurses bestow on particularly odious patients either. There’s “The Lord of the Flies” in bay ten. “Mrs. Jabba” and “Jabba Junior” in room twelve. Not to mention “Your girlfriend,” drunk and stupid with garlands of crusted vomit in her hair screaming profanities in room six.

“Hey, Panda, can you keep your girlfriend quiet?”

“She’s my sister and no, I can’t.”

4. Maybe try to get a few procedures. Certainly offer to suture lacerations. You probably won’t get a chest tube but if you are interested, we might coach you through a central line or two. You can check for blood in stool all you want.

5. Look at a lot of CT scans, ultrasounds images, and films. This is high yield because almost everybody gets some imaging study or another and you can sit with an attending who, while not a radiologist, can point out most of the findings you are likely to encounter in any but the most obscure specialties.

Things That Will Suck
Everything if you don’t like it. Not everybody likes the pace. Some people like to deliberate a tad more and have just a little more information before they make a decision. They call this specialty “Internal Medicine.” No shame in that, of course. With the exception of those lazy bastards in PM&R, we are all a team and every member of the team is important. But if it bothers you to not have a clear diagnosis on every patient you will be desperately unhappy. I can only hope that you, at least, do not become one of those specialists who look disdainfully at Emergency Physicians when we do not immediately identify an obscure but obvious disease involving an organ system which they have spent seven years of residency and fellowship studying in excruciating detail.

Or, you just might be lazy and miss the opportunity to just sit around doing nothing like you do on a lot of other services.

You will also see a lot of smelly, nasty, obnoxious, and sometimes dangerous patients. You will either revel in it or not but there they are, scooped up and delivered fresh from the street in their natural condition which often involves a protective crust of vomit, feces, and other unspeakable substances. They don’t get sanitized for your protection until much later.

Cool Things About the Rotation:
If you can get over your brainwashing that every patient encounter must be a long, slow, mutually gratifying and environmentally pure simultaneous orgasm with metaphysical post-coital spooning, what’s there not to like? A huge variety of patients. Fast pace. Sassy nurses who won’t kiss your ass. Major trauma. Procedures. Even a lot of primary care if that’s your thing. And if you have a heart and like medicine at it’s most visceral, this is your specialty as it deals with a chief complaint which is addressed immediately and completely leading generally (believe it or not) to immense satisfaction on the part of the patient (if they are really sick, I mean, and not just looking for drugs or attention).

None. Zip. Zilch. You will work shifts and at most places, the medical students will only work the “rotator” schedule which is something like fourteen days in a month. Sure, the hours are screwy but I’ll take vampire hours with twelve or fourteen days off a month over Q4 call and 13-hour days with one day off every week.

Slacking Potential:
Good, because you are not tightly supervised unless you want to be an we are usually too busy to care where you are. It’s not like we have a lot of scut for you to do. But why would you want to be a slacker given that the hours are so good? Nothing motivates me to work hard more than the sure knowledge of when quitting time is. This is not to say that you will always get out exactly when you shift ends but at least you know when to start wrapping things up.

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 4

(Disclaimer: I hated surgery with the burning fire of a thousand suns so you may have a different experience-PB)

General Surgery

Your Real Responsibilities:
Nothing. You’re a medical student. You don’t count. Your job on the surgery team is to be the butt of jokes and to give everybody someone to laugh at. Hey, I don’t make the rules. I’m just telling you how it is.

Your Pretend Responsibilities:
Post-operative management of patients on the wards. Assisting in the operating room although you can easily be replaced by any one of many finely crafted retractor frames. I all but refused to go to the OR after I learned about these things. “You mean to tell me that there is no reason for me to stand in the same place holding a retractor for six hours when all you have to do is hook up the frame and clamp the retractor to it? Why those no good, sadistic, lazy….”

But I digress.

Your other pretend responsibilities will include following patients as you would do on a medicine service as well as attending clinic where you will pretend to evaluate patients before presenting them to your attending.

Things You Should learn:
Ranson’s criteria are huge. I must have been asked about these at least once a day. (Ranson’s criteria help predict mortality from pancreatitis.) Also things like Charcot’s triad (fever, jaundice, and right upper quadrant pain), Reynolds pentad and other eponymous collections of symptoms. Surgeons love these things and if you can rattle them off your attending will think you are the best medical student ever even if you are an otherwise lazy piece of shit.

Don’t forget Panda’s Triad which is boredom, disinterestedness, and clock-watching.

Know the twenty-or-so common abdominal surgeries, their indications, and how they are done. If you know what a whipple is, for example, and the relevant anatomy you will do just fine in the OR under the pimping gun. Don’t ever say “Roux-en-Y” unless you know what it means. Also, don’t ever go into a case without at least knowing the patient’s name, his diagnosis, and the planned procedure.

Know how to scrub and what to do and where to stand in the OR. Extra points for knowing how to “self-glove” in a sterile manner because you might be expected to do this. Apparently, many scrub nurse have a clause in their contracts stating they don’t have to hold gloves for vagrants, migrant workers, cheerleaders, medical students, and others with no real purpose in their operating room.

Also know about wounds, how they heal, and the various methods used to dress and debride them. And for Mohammed’s sake learn how to tie a few common surgical knots. Practice before your rotation. Nothing says “dork” like throwing a granny knot.

Things That Will Suck:

No. Really. If you don’t like surgery (and you will know how you feel about it after, oh, maybe five minutes) It all blows hard combining as it does all of the worst aspects of every other rotation with real hard work. Standing in a case holding a retractor or trying to stay awake and not falling into the sterile field (which I saw happen) is grueling. Medicine, by comparison, is not hard, just annoying.

The higher than usual numbers of malignant attendings and tired, bitchy residents just adds a little kick to the fecal jumbalaya which is your surgery rotation. But I have no sympathy for them and you, also, need to resist that temptation. Sympathy is in the dictionary between shit and syphilis. We lay in the beds we make. Nobody holds a gun to anybody’s head and forces them into this career. It sucks but it’s not as if your tired, pissed-off residents didn’t know this before they matched. Your third year rotation gives you a pretty good overview of the life of a surgery resident. You will be getting up just as early and leaving just as late. I hated every single minute of my surgery rotation, the only good thing about it being that it was my first rotation of third year and nothing that came after even came close to sucking as hard.

Cool Things About the Rotation:
Nothing. Seriously. If you don’t like it and have no interest in being a surgeon it is all a grind. Even surgeons will tell you this. Surgery is a calling. You either love it to the exclusion of almost everything else in life or you will resent it mightily. Family medicine, psychiatry, Emergency Medicine, and Internal Medicine residency programs are littered with ex-surgery interns who discovered that they had other interests in life and that, while it may have seemed cool at one time, it just wasn’t worth it in the end. Married surgery residents have almost a one-hundred percent divorce rate for a reason. You cannot have a family life as a surgery resident. Period. The eighty hour work week is still a joke in most programs and the simple mathematics of the week dictate that you can’t have Q3 call, work 100 hours a week, get the bare minimum of sleep, and spend the time with your wife and family that they deserve. There are 168 hours in the week. How much sleep do you need? Forty hours a week? Do the math. It’s five long years, sometimes six.

By contrast, as an Emergency Medicine resident I work about sixty hours a week for three years and will probably make more as an attending for half of the hours and about a third of the bullshit.

But you know, it’s surgery. There is no question that it is a useful, highly challenging field which will never be replaced by mid-levels or outsourced. If you’re young, healthy, and motivated and like this kind of thing you may find your true calling in life on your surgery rotation. A lot of my classmates loved this rotation and yearned for fourth year when they could line up more of it.

Useless like most medical student call but not completely useless. On trauma call you will be handed the “Monkey Sheet” (the History and Physical) and filling it out during the trauma will help your tired residents immensely. And you may be a real help during cases late at night or early in the morning when nobody is around. You’ll still hold the retractor but at least you’ll be standing opposite the surgeon and not leaning in at an impossible angle.

Slacking Potential:
Excellent. Other than rounding in the early, early morning your residents and attendings will be busy during the day and not making a career out of leading you and the rest of their entourage around the hospital. I’m sure your school has a minimum number of cases in which you must participate but nobody ever failed the rotation for not getting into a whipple. Maybe during your rotation nobody needed one. A colectomy here, a hernia repair there and you can build up enough cases to keep the wolves from your door. After this there are a dozen perfectly legitimate reasons not to scrub in on a case without having to ever resort to the “I’ve had the runs all day” ploy. If you don’t like it and would rather be a Slurpee jockey than a surgeon, OR time is pretty low-yield anyways. No reason to kill yourself.


How to Scrub 1
How to Scrub 2
My First Day of Third Year

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 3

Internal Medicine (“Medicine”)

Your Real Responsibilities:
Nothing. You’re a medical student. Remember those red-shirted crew members on Star Trek? That’s kind of like you. Your only function is to walk around filling out the scene. Sometimes bad things will happen to you, sometimes you will provide comic relief, but mostly you will just fade into the background, indistinguishable from any other medical student.

Your Pretend Responsibilities:
Managing patients on the wards. Seeing patients in clinic and presenting them to your attendings and residents. Admitting and discharging patients under the supervision of your residents and learning to write the appropriate orders.

Things You Should learn:
Everything. Internal medicine (along with General Surgery) forms the backbone of the entire medical profession. It is medicine in its purest form complete with meticulous history-taking, a thorough physical exam, a comprehensive differential diagnosis, a sound plan with the appropriate testing, and either a definitive treatment or the appropriate referral. It is both traditional, as the internal medicine ethos would not be unfamiliar to the ancients, and cutting-edge, as new research is continuously incorporated into the profession.

So there is a lot to know. Rather than trying to list things, let me give you one of the only really useful mnemonics in medicine which is “VINDICATE.” I generally hate mnemonics but this one will let you systematically come up with a differential diagnosis from which further testing and treatment may be derived. The causes of every illness known to man are:

Neoplasm (Cancer)

When you’re in a bind and staring at and acre or two of blank space on your note for your assessment and plan, just take a deep breath and remember VINDICATE.

Things That Will Suck:
Did I mention it was medicine? As bears shit in the woods, the Pope is Catholic, and death invariably follows taxes, medicine attendings love to round. And round and round and round, often well beyond the point where you care about anything but making it stop.

Rounding, for those of you who don’t know, involves visiting, as a group, every patient on your census to discuss their illness and the plan. Surgery rounds are sometimes of the variety, “Patient looks fine from door, let’s move on.” Medicine rounds, however, proceed at a glacial pace as every single aspect of the patient, his disease, his lab values, and his prognosis are discussed in excruciating detail. This is where you may have a 45-minute ad hoc lecture about a patient’s normal but slightly low sodium value and what it means for him. Then you will discuss the next patient’s potassium for half an hour.

Merck developed a probe that gave continuous readings of serum electrolytes but they had to take it off the market after internists started hanging themselves with their stethoscopes.

Not to mention that every possible cause of the patient’s symptoms, no matter how unlikely, will be trotted out like so much horseflesh to be poked, prodded, examined, and finally sent back to the corral. It is a good way to learn medicine, don’t get me wrong, but my feet hurt all the time on that rotation and I developed plantar fasciitis from standing up and walking for eight hours a day.

“Don’t they have anything better to do?” you ask. Well, no. This is what they do. Internal medicine is light on the procedures but heavy on the thinking.

Cool Things About the Rotation:
1. Morning report: Almost every program has a formal teaching session in the morning where a case is presented to the residents. It is usually in a question and answer format where the presenter starts with the presenting complaint and symptoms and the residents ask appropriate questions about the history, review of systems, physical exam and all the other elements of a good patient encounter. This leads to the creation of a differential diagnosis which is narrowed down to the most likely disease after which a short presentation on the final diagnosis is given. For my money, this is the best way to learn medicine. It’s interactive, it’s fun, and even the pimping is usually in good spirit.

2. The opportunity to rotate on sub-specialty services: I landed nephrology and cardiology (two weeks each) as my subspecialties during my two-month-long medicine rotation. Nephrology attendings, for their part, are like general medicine attendings on crystal meth, at least when it comes to their preoccupation with electrolytes and they are, as a class, perpetually exasperated that their medical students, most of who are just trying to survive, cannot identify garden-variety mixed acid-base disorders. Still, these kinds of rotations give you good exposure to the whole range of medicine.

3. Medicine is very cool. Internists have my deepest respect but it’s not something I wanted to do, what with my short attention span and poor memory.

Useless, like most medical student call. You’ll basically just follow your resident around as he grinds out admission after admission in the best cookie-cutter fashion. As there is no difference between an admission done at 8PM and one done at 3AM (except that at 3AM you are too tired to give a crap) there is no reason to lose sleep. You can learn all you need to know and still get a good night’s sleep except that your faculty is bound and determined that as they suffered, so shall you.

Slacking Potential:
Medium. Rounds don’t actually last all day. You may have a couple of hours to vanish and either take a nap or study. Generally, after formal rounds you have “work rounds” where your residents will go back to their patients and implement the plans discussed on rounds. Since you are not responsible for any aspect of patient care, your presence is not required and after you make yourself aware of what is going on with all the patients you are following, the day is pretty much your own unless until sign-out in the late afternoon. Like most inpatient rotations, expect early hours but not as early as OB/Gyn or surgery where they round early to get it out of the way so they can do their real work.


A Typical Day on a Medicine Service
A Typical Day as a Medical Student Part 1
A Typical Day as a Medical Student Part 2

Panda’s Quick and Dirty Guide to Third Year Rotations: Part 2


Your Real Responsibilities:
Nothing. You’re a medical student. You don’t count. I hear that in Arizona they’re going to replace medical students with migrant workers. Sure, they’ll have to pay them minimum wage but this is peanuts compared to the cost of educating a medical student. This way the hospital will save money, the employees will still have somebody to look down on, and the migrant workers can always mop the floors or do other useful work, something that you can never get out of a medical student.

Your Pretend Responsibilities:
Managing pediatric patients on an in-patient service. Attending pediatric outpatient clinics and learning to handle the breathtaking excitement.

Things You Should learn:
Presentations and treatments for common pediatric problems like rashes, diarrhea, colds, and vomiting. Developmental stages of childhood, normal milestones, and what to do or who to call if the child is not meeting them. Common congenital conditions. The major chromosomal abnormalities (like Trisomy 21), common congenital heart defects. Diagnosing and managing the more serious pediatric diseases. Identifying child abuse (a big one in my book). Learning how to examine sick and well kids without having them scream in fright during the whole exam.

Otitis Media. The big one. Deserves a whole blog of its own.

Things That Will Suck:
1. Well, it’s pediatrics. It all sucks if you don’t like kids. I have my own kids so I had a running start at disliking it. Other than that it’s not too bad. Inpatient pediatrics is as bad (or as good) as inpatient medicine. You will round, present, and take call. The primary philosophical difference between pediatrics and medicine is that most kids will get better and make a complete recovery, something you will not see that often on an adult medicine service where you sometimes feel like you are playing “Keep Away” with the grim reaper. But ward months are ward months and call is call. Rounding sucks no matter on what rotation you do it.

2. There is no clinic known to man more boring than outpatient pediatrics. Most kids are just not that sick but their parents bring them to the doctor with distressing frequency. The major culprit is the “Well Child Check.” The Well Child Check is a periodic screening exam to make sure that kids are growing appropriately and have all of their immunizations. If you can think of something more mindless than asking the same questions over and over about usually healthy children and plotting their height and weight on a growth chart then you have probably worked at more crappy minimum wage jobs than most of us.

Like two men and a ham, pediatric clinic can seem an eternity. The hours flow like thick syrup. Having to ask the questions in Spanish cuts the excitement in half.

Cool Things About the Rotation:
1. Well, they are kids after all. Who doesn’t like kids, especially if they are not yours and you don’t have to take them home? They are kind of cute and every now and then you will get a stupid smile on your face which you can’t get rid of.

2. Their are few things as gratifying as seeing a really sick kid get well through medical intervention. And, while you may not see this as a medical student, running a successful code on a child is probably the best feeling in the world (just like having to call the code is one of the worst).

3. The residents and attendings are fairly benign. Malignant people, as a rule, don’t go into pediatrics preferring as they do to keep their options open in Med/Peds. Additionally, if you want to know the one specialty that is a calling it’s pediatrics. The pay is bad, the hours are long, but people do it because they love it.

Fairly lame like most medical student call. You will soon grow tired of hiking down to the Emergency Department to help admit yet another asthma exacerbation. Or dehydration and fever from gastroenteritis. Still, kids are generally not as sick as adults even when they are admitted to the hospital so for the same size census, you will get fewer floor calls. I suppose that’s something. You know how I feel about losing sleep. As a resident it’s unavoidable as not only are you responsible for the patients but you are also getting paid, things that are not true for medical students. Have I said this before? I think it’s dumb for a medical student to answer floor calls as he is just going to have to page his resident for guidance. I say eliminate the middle-man.

Slacking Potential:
Not so good. Terrible in fact. It’s just medicine for kids with all of the rounding, morning reporting, conferencing, and other mandatory activities. When you’re doing your ward months you will pretty much be stuck with your team all day, every day so if pediatrics isn’t your bag you are out of luck. Clinics are, of course, mandatory, usually pretty busy, and dull.

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 1

Obstetrics and Gynecology (OB/Gyn)

Your Real Responsibilities:
Nothing. You’re a student and you don’t count. Every medical student in the hospital could vanish and apart from less crowding on the elevators, nobody would notice.

Your Pretend Responsibilities:
Following pregnant woman pre-, ante-, and post-partum. Assisting in vaginal and Cesarean deliveries. Assisting in gynecological surgeries including hysterectomies, vulvecvtomies, and salpingectomies. Seeing patients in clinic with various gynecological problems who you will present to your attendings and residents. You will probably “shadow” a resident at first. Your level of independence will depend on the school, the attendings, and your level of interest.

Things You Should learn:
1. Pelvic Exams. Don’t be squeamish. They call it a bimanual for a reason. The first fifty you do all you’ll be able to say is that it’s warmer in there than outside but after a while you’ll get the hang of it.
2. Assessment of labor. Learn how to assess the cervix for dilation and effacement. Recognize the stages of labor and which stage the woman is in if you feel the baby’s ears while checking the cervix.
3. Recognizing common complications of pregnancy (placenta previa, accreta, malpresentation, pre-ecclampsia, etc), knowing who to call and what to do in the meantime.
4. Treatment of STDs.
5. Causes of abnormal vaginal bleeding and what to do about them.
6. Common gynecological malignancies.

Things That Will Suck:
1. The hours. The early, early hours. Best to just suck it up and go to bed early every night. Tivo American Idol if you must but it is not unusual to pre-round at 0500 on OB which means that unless you sleep in your clothes and don’t brush your teeth you will have to get up at hours that would make dairy farmers cringe.

2. Vaginal Discharge: Are you some kind of freak? How could anybody possibly enjoy looking at and smelling green frothy discharge pouring out of an orifice that would turn Puff Daddy gay if he were to merely gaze at it. I have seen some horrific sights in Gynecology clinic. Visions of terror that have made even hardened OB/Gyn residents recoil in horror while their less-seasoned colleagues wept and spread ashes on their faces. They don’t call it the whiff test for nothing.

3. OB/Gyn residents. I’m conflicted on this. They’re not necessarily malignant, just cliquish. Definitely cold towards medical students unless you really show an interest which, frankly, is hard to do if you’re not interested (obviously).

Cool Things About the Rotation:
1. Once you get past the feces, urine, smells, screaming, and other truly frightful aspects of childbirth which they don’t show on the Discovery Channel (but I don’t have HDTV) it is kind of cool. Everybody is usually pretty happy to see the baby, even mothers who you know will be going back to their crack pipe an hour after discharge. Hope springs eternal.

2. A good variety of things in one rotation, ranging from primary care to incredibly intricate oncological surgeries. If you don’t like looking at “wedding tackle” this is also your rotation. Plus, although there are exceptions, female patients are generally less nasty than men.

3. Clinic weeks: Generally, when you are on the outpatient part of your rotation the hours will be nine-to-five with no call.

Idiotic, like most medical student call. Still, take advantage of the opportunity to get more involved in deliveries at night when there are fewer people around and you have a better chance to assist in a C-section doing something more than holding a retractor. You will mostly do call in OB triage.

Slacking Potential:
Not so good. On clinic weeks you definitely have to be in clinic and it’s hard to stand around doing nothing in that kind of exposed environment. Still, you can work slow and “just miss” picking up a chart from the door of a new patient. Although I kind of liked OB/Gyn, I can understand completely how after a couple of “close encounters” one might decide that they have had enough.

On Obstetrics you will have to round and since OB is busy, they have very well organized rounds and morning reports. No getting out of it. If you don’t want to go to the OR you can probably hide-and-slide when you are on “Benign Gyn” or “Tumor Gyn” but you will get dragged into a certain number of C-sections even if you have sworn an oath to all of the pagan gods that you will cook and eat your own entrails before you would match into OB/Gyn.


What you will do an intern.

Tomorrow Will Suck

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.

Scrubbing In: Part 2

All Dressed Up, Nowhere to Go

Are you essential to the running of the OR? Will your skills be of any value?

Of course not.

On the other hand, just because you don’t know your ass from a hole in the ground when it comes to surgery does not mean that the team does not want you there. On the contrary, because everyone likes to show off to an appreciative audience your attendings and residents will be happy to have you there even if they will occasionally poke fun at you.

You would have to be a hoary old misanthrope not to appreciate the opportunity to demonstrate what you do well to someone who has not seen essentially the same resection of the colon fifty times. There is a certain thrill in impressing the new guy and, believe me, you will be impressed.

While it is true that many surgeons have personalities that would make Ghengis Khan wince in shame, there is no denying that over the course of their training they learn amazing skills. Be appreciative but do so silently because, as I have said elsewhere on this blog, nobody likes a tool.

Don’t be a tool.

So there you are. Scrubbed in. Ready to go. At this time if no one has told you, you should ask your resident or attending where she wants you to stand. Usually you will stand to the right of the attending. The resident will stand across the patient from the attending. This is not written in stone as sometimes it might just be you and an upper level resident loosely superivised by an attending who may or may not think it necessary to scrub in.

Your job now is to keep you mouth shut, your eyes and ears open, and to above all not do anything stupid. Leave your ego at the door. Being silent and respectful neither makes you a suck-up nor a tool. Do not take any good natured ribbing personally. Hell, don’t take anything personally.

I have a friend who’s attending threw him out of the OR after cursing at him and then throwing a few (non-sharp) surgical tools at him. He had forgotten to take off his ring and the attending could see it under his glove.

In a situation like this, do you go to your school’s office of cultural sensitivity and file a complaint? Of course not. He’s a surgeon. His personality, failed marriage, and long hours are more than enough punishment. All you will do is establish a reputation as a cry-baby and somebody who can’t take the heat. At the very least my friend always remembered to take of his ring so we can probably file the whole incident under “learning experiences.”

I keep coming back to not being a tool. For your surgery rotation more than any other you wil have to grow a thick skin as this is the rotation which cares the least for your hopefully non-fragile ego.

If you are asked to hold something hold it. In fact, your primary job will very likely be to hold retraction which usually involves holding body cavities open. Either that or to hold up limbs during orthopaedic procedures. Not too much else, if even that, will be expected of you until you show a little bit of interest and a little bit of the ability not to crush important organs.

Sounds easy but occasionally you will hold retractors for what seems like and often is hours. Pick up a light book and hold it out at arms length. See how long you can do it. That’s what holding retraction can feel like.

No doubt your school will have a suture lab during the end of second year at which time you will learn the mysteries of both suturing and knot tying. Pay attention and practice on your own. It is unlikely that you will be asked, on your first day, to close an incision but you might be asked to tie a few knots and nothing says “loser” quite like not being able to tie a simple sugeon’s knot. If you can do it, on the other hand, don’t expect any accolades. It is a basic skill, after all.

You might also be asked to use the suction catheter to keep the surgical field clear of blood and fluid. Watch what the resident does and imitate him. Do not poke and prod randomly and when in doubt, ask.

Invariably as the hours creep by your legs will get tired, you will itch all over, and you will regret skipping breakfast. Or nature will call with increasing urgency. Tough luck. You will just have to gut it out.

A few pieces of random advice:

1. Don’t lock your knees.

2. Do not doze off and fall into the surgical field. It can happen. Some operations are long and boring especially if you are not actually doing anything but watching.

3. Eschew the extra cup of coffee in the morning.

4. Turn off you pager. Residents and attendings typically put theirs on the board in the OR so the circulating nurse can answer their pages but you are just not that important.

5. Study the relevant anatomy before the operation. Typically you will look at the OR posting sheet the night before to determine where you will be. At the very least have a copy of Netter’s in your locker so you can quickly brush up on the arteries supplying the colon or anything else you might be asked by way of pimping.

6. Be scrubbed in and ready to go before the attending. This is not always possible but you should do it if possible.

7. Try to relax. Remember, as a medical student you have no real responsibility. Whatever happens you will be done with the rotation in a matter of weeks. If you don’t like it, tough it out.

8. If you really don’t like it surgery more than any other rotation offers you abundant opportunities to “hide and slide.” There are a thousand reasons, some of them actually quite good, not to scrub in on cases. In the end nobody will really keep that close track of you and you are only depriving yourself.

With that being said I had a friend who knew that he wanted to do psychiatry and nothing else so he saw absolutely no reason to to get jiggy on his surgery rotation.

let your conscience be your guide.

Scrubbing In: Part 1

Yes, the Scrub Nurse is Laughing at You

The dreaded day has arrived. You are on your first surgery rotation. After a brief orientation you are told to report to the operating room to “scrub in” for your first surgey.

Get ready to run the gauntlet. You have the potential, in the next few hours, to screw up pretty much everything. Either that or you will do everything right and blend into the woodwork which is about as much as you can hope for on your first day.

I just want to give you a few general guidelines about what to do as a medical student in the OR. By all means take what I say with a grain of salt because I am not a surgeon, local customs vary, and maybe your surgeons are caring, compassionate souls who will calmly take you by the hand and lead you gently into the world of surgery.

Or not.

The operating rooms are generally clustered in one part of the hospital. Street clothes and more importantly, street scrubs (the ones you wear to and from the hospital) are not permitted in this area. Even before you enter the OR itself you will need to change into clean OR scrubs, shoe protectors, and a hair covering of some kind.

Now, while it is true that the OR suites are not sterile, the idea is to minimize the introduction of environmental pathogens. When you are in the hallway outside the OR it is not generally necessary to wear a mask. On the other hand, everytime you go into the OR itself you must have a cap and a mask on at a minimum even if you are not scrubbed in.

In other words, if you are asked to help position the patient you can enter in just scrubs, shoe covers, a mask, and a cap. Likewise if you are just observing from outside the sterile field as you will often do.

You will notice also that the nurse or tech who is prepping the patient will not scrub in but will wear sterile gloves as he shaves, swabs, and otherwise prepares the patient.

But you are instructed to scrub in. What do you do?

Outside the OR you will find the scrub sink. Obtain a scrub pad, open it, and place it on the ledge over the sink. (Usually these pads are pre-loaded with hibi-cleanse or other surgical scrub soap.) Next put your mask on because once you scrub your hands you can’t touch anything that is not sterile and your mask, my friend, is a hotbed of bacteria and other nastiness.

Usually either goggles, glasses with side-shields, or a mask with a transparent face shield are required in the OR. These things will all fog up on you quickly if you don’t take certain steps. Most surgical masks can be fitted to your face by bending the nose guard. Still, I always found that either the face shield or my glasses would fog up no matter what I did. Consequently I started putting a two inch strip of tape across the bridge of my nose, taping the mask flat and sealing it to my nose.

Do whatever it takes. You may laugh but you might want to take a mask home and try this to see if you can get it right. I prefer goggles to the face shield so unless your residents tell you otherwise as long as you have a mask on and your eyes are shielded you can do whatever you want.

Put everything on right and make sure they are comfortable because once you start scrubbing in you can’t touch your face or anything on it for the duration of the operation…and I have been in some that lasted almost eight hours.

Unless it is emergency surgery (as you may do on a trauma surgery rotation) scrubbing your hands should take you at least five minutes. This is why their is a clock over the scrub sink. If your residents and attendings only scrub for two minutes that’s their perogative but you, my friend, need to do it right.

First take the pick out of the scrub package and clean under your nails. The water is usually turned on by a foot valve or other no-touch mechanism. You will not touch anything non-sterile from now on.

Next, carefully and methodically scrub your hands and arms up to the elbow. First use the brush side of the pad to scrub your fingernails. Then, systematically scrub every finger, the palm, and the back of each hand in turn. Scrub hard with the sponge side.

Oh wait. Did you take off your watch? How about your rings? Sorry. All rings and jewelry below the elbow must come off. Better to leave these things at home. I put my wedding ring on a loop attached to my ID badge. Do not leave anything on the scrub sink that you don’t want to walk away.

After scrubbing one rinses, starting at the hands and letting, as much as possible, the water run down your arms away from your hands. Just do what your residents do. Do not touch the sink, the faucet, or anything else for that matter. Keeping your hands away from your body enter the OR by opening the door with any part of your body but your hands.

I should also mention that before you scrub you need to let the circulating nurse know your glove size so the scrub nurse will have them for you once you enter the OR. Typically you will wear green indicator gloves under your outer gloves. The green indicator gloves provide an extra protective layer and also show you if your outer glove is torn.

Since your hands are still wet, the scrub nurse will hand you a sterile towel. Keep the towel away from your body. Start at the top of your arm and dry in one direction. Then reach under the sterile towel to the hanging end opposite from the side you used and switch hands to dry the other hand. Drop the towel somewhere, where depends on your OR’s procedures but don’t touch anything while you do it.

While gowning and gloving without assistance is a skill you need to learn, in the OR the scrub nurse will hold your gown up for you to put in your arms. Put them into the sleeves but do not extend anything more than the fingers past the cuff. Usually the circulating nurse will tie your gown for you in the back. Note that only the front of your gown, your arms, and hands are going to be considered sterile so a non-sterlile person can tie you up in the back.

At this time the scrub nurses will hold up your first glove oriented for you to put in your hand. Reach deep into the glove but don’t touch the floor for god’s sake. For your other hand the scrub nurse will hold the glove up for you but in this case you will reach under the cuff with your gloved hand and open it up for your other hand.

Sometimes your fingers will go in the wrong fingers of the glove. Don’t worry and do not reach over with your ungloved hand to adjust your glove. Even though you have scrubbed your hands, all you have done is knocked down the number of colonies. Your hand is non-sterile even after scrubbing and if you touch your gloved had with it you will be asked to scrub out and repeat the whole procedure.

Once you have both hands gloved you may, with perfect aplomb, adjust your gloves to your heart’s content as your gloved hands are both sterile.

Now here’s the tricky part. The front of your gown has a cardboard tab attached to the wrap-around ties. Grab one tie with one hand (pulling it free of the tab) and hand the red end of the tab with the other tie attached to it to the circulator (or anybody) being careful not to touch your gloved hand to the non-sterile person you hand it to. Spin once to wrap the closure around your gown, hold the two ends of the closure and let the circulator pull the tab off of the cord. Tie your gown with the cord.

There you go. You are now scrubbed in. Keep in mind that the scrub nurse, the circulator, and anybody else who loves to harrass medical students will be watching you intently to catch you in a mistake. Maybe you touched something non-sterile. I once, for example, reached up to adjust my goggles and had to “scrub out” and repeat the whole procedure from the top.

Don’t take it personally. While it is legitmate fun to pick on medical students, the insides of the human body provide an ideal culture medium for bacteria, spores, and viruses. Surgical infections are serious business and the best way to deal with them is not to let them happen.

A word about the sterile field. You will note that the patient will be completely draped in sterile coverings leaving only the operative site exposed. The operative site will have been scrubbed before the drapes went on. The sterile field extends to all sides of the operative site which are covered by a sterile drape. Your hands, your arms, and the front of your gown from slightly above waist level to about the clavicular line are part of the sterile field. Never drop your hands below your waist. It is acceptable to fold your arms if you are just going to be standing around. Never touch anything above your waist which in not part of the sterile field.

By all means rest your hands on the sterile field. That way you will not get into any trouble. You can play a game of soitare on the sterile field (if the cards are sterile natuarally) without comprimising sterility as long as you never touch anything outside the field.

The scrub nurse’s table is part of the sterile field and is covered in a sterile drapes upon which sterilized instruments are placed. These instruments are passed back and forth between the patient and the table but as long as they don’t leave the sterile field they are sterile.

Are you seeing a pattern here? Everything in the OR is structured to keep a small area of the room sterile. The point of entry is the scrub nurse who always takes her job seriously. She may be defferential to the attending but she is not afraid of residents, interns, and least of all medical students. Do what she says in regard to protecting sterility. If you are in doubt, politely ask her what you should do.

Next: Retracting 101.

First Day on the Wards: Part 2

You Are Worthless and Weak

What is rounding?

At it’s most basic, rounding is the process of visiting hospitalized patients as part of a team. The team usually consists of an Attending Physician, a collection of upper level and junior residents and medical students.

The Attending Physician, or the “Attending” is the boss. He is usually a senior physician with academic and clinical credentials who is responsible for all of the patients on his service. At medical schools he is most likely a professor and you may also have seen him lecturing to you during first and second year.

The day-to-day running of the service is the responsibility of the upper level resident. On a medicine service this is usually a third year resident who is in his last year of training. He will discuss the patients with the attending who will will rely on his judgment and skill in all but the most unusual cases.

The lower level residents, such as interns who are in their first year of post-graduate medical training, are responsible for the nuts and bolts of patient care. They are assigned patients and follow them, managing the many details of their treatment. This includes both working up new patients (clarifying their history and developing a plan) as well as managing existing patients.
Basically the lower level residents manage a patient from admission to discharge.

Your job as a medical student is to learn, in your turn, the nuts and bolts of patient care as well as to increase your clinical knowledge. You do this by following patients of your own, usually under the direct supervision of the lower level residents.

Nobody is going to expect you, on the first day of third year, to pick up a new patient, formulate a well considered plan, and implement it resulting in a miraculous cure. Nor are you going to be, as you may see on various popular television dramas, at constant odds with your team as you try to fight the corrupt system to get your patient the care he deserves. This is not “Patch Adams.” No matter how smart you think you are on the first day of third year you are going to feel like the biggest idiot on earth and you will be thankful if the worst thing that ever happens to you is that you are ignored.

Additionally you will probably see more straight-up medical knowledge and clinical skill in one place, represented by your Attending and upper-level resident, than you ever knew existed.
Consequently the keys to third year are to keep your mouth shut and your eyes and ears open. You also need to be enthusiastic and willing to work hard without, it must be added, being a kiss-ass about it.

Don’t be a tool. That is, don’t be that guy who asks idiotic questions the answer to which he could look up himself except he likes to hear the sound of his own voice and really thinks the Attending doesn’t know he is a tool.

Silence is golden because invariably after being assigned a patient or patients you will be required to present them.

Typically you will walk down the hall and stop at a patient’s room. After a brief pause, the person following the patient is expected to begin a short, succinct narrative describing the patient’s history, what happened since the previous day, and the plan for the patient. This narrative includes many things but if you think about it the SOAP note described in the previous section is a good place to start. If you write a good note before rounds and understand what is going on with the patient presenting to the team should be a snap.

Naturally you should know any pertinent lab values and the meaning of either their normalcy or derangement. You should also know what consultants have advised, either by talking to them informally (a “curbside” consult) or the contents of their formal written recommendations.
Any studies or images ordered on the previous day also need to be reviewed. You should look at the films if possible ( this is getting easier because many hospitals have them on line) but at least read or listen to the dictated reports.

Rounds can be a lot of things. They can be grueling tests of your endurance as is typical on an internal medicine or medicine subspecialty service. You might, for example, spend an hour in front of a patients room listening to the Attending opine on the meaning and significance of a low serum potassium followed by a half-hour discussion of his differential diagnosis. A learning experience to be sure but quite tiring after the first five hours.

Get comfortable shoes.

There is such a thing as “speed rounds” which are typical of most busy surgery services. In this case the attending wants you to be succinct . Typically the discussion will focus on the presenting complaint only with an eye to cormorbidities only as they impact the progression of the surgical patient towards his usual state of health.

In other words, your goal is to diagnose his ischemic bowel, surgically repair the damage, and manage his recovery to whatever good or bad state of heath he was in before the operation. Surgeons have full time jobs in the operating room so while rounds are important, they are a necessary evil.

Occasionally you will have “sit down” rounds where the patients will be discussed around a table after which you will go as a team for “speed rounds.”

A note on rounding etiquette.

Do I need to state the obvious that you should be attentive to the attending and the chief resident? Pay attention and keep your mouth shut unless asked a question or unless you have something relevant to add to the discussion. Maybe even if it is a joke but you should carefully assess your Attendings disposition before you make a foray into humor.

Generally, as a medical student you will have very little of relevance to add to the discussion. Your attempts to demonstrate your limited knowledge will make you look like a tool so look interested, stand where you can be seen, and keep yer’ cake hole shut.

Since one purpose of rounds is for the Attending to confirm physical exam findings, you should accompany him into the patient’s room and stand ready to assist him in his physical exam. Not only is this expected but you will also pick up invaluable physical exam pointers which will serve you well in later years.

Keep notes. Often your resident or Attending will make what you think is an off-hand remark about a lab value she’d like to see. Meaning that she’d like it ordered so she can see it. Don’t hesitate to clarify the plan before you move to the next patient by confirming your impression of what is needed.

Of course you need to be punctual for rounds, even if they start at some ungodly early hour like they will for most surgery rotations. You also need to dress up, not down, on your first day unless explicitly told to do otherwise. Many Attendings are “old school” and expect a shirt and tie for rounds. If your Attending and residents are in scrubs then you can emulate them.

A word about “pimping.” During the course of rounds (and during surgery, clinic, and just about every other activity for that matter) your Attending or residents will ask you questions to test the limits of your medical knowledge. This practice, known as “pimping,” is traditional and a valuable part of the learning process. Invariably however you will be asked a question which you know you should know but don’t and will stand gaping like a fish making apologetic noises or inarticulate grunts.

Don’t sweat it. Nobody expects you know everything. More on pimping in the next section.

What are the keys to rounding as a third year?

Enthusiasm, punctuality, attention to detail, and a little bit of humility. You are not going to save the world and you are not, despite what anybody tells you, a vital part of the health care team.

First Day on the Wards: Part 1

Are We Healing People Yet?

So there you are, on the first day of third year about to start your clinical training. Two years of lectures behind you, thousands of facts disintegrating in your brain every day, and you are standing sheepishly in your new short white coat at the nurse’s station about to start your first real day of your new career without a clue as to what exactly is your job and what you should do first.

You’ve had the orientation, of course, where you are told what is expected of you but somehow it doesn’t exactly translate on a Monday morning at 6 AM surrounded by the bustling world of an academic medical center.

Relax. Here’s how a typical ward rotation works.

First thing: By “wards” we mean a rotation dealing with patients who have been admitted to the hospital and who reside there for the duration of their treatment. Some rotations are all “outpatient” (as opposed to wards which are “inpatient”) and you will be seeing patients in a clinic. Family medicine is a good example of an outpatient rotation. We will discuss these rotations in a later post. Just keep in mind that even on an inpatient rotation you may spend some time seeing outpatients in a clinic setting.

As you will find out, third year is divided into short blocks, typically two months long, during which you cover all of the major areas of medicine such as Surgery, Obstetrics and Gynecology (OB-Gyn), Internal Medicine (“Medicine”), Pediatrics, Surgical Subspecialties (such as Urology, Opthamology, and Otolaryngology), Psychiatry, and a few other things depending on the priorities of your school.

These two month blocks are typically further broken down into shorter sections. You might, for example, do one month of General Surgery and one month of Vascular Surgery in a two month surgery rotation. On a two month medicine rotation, as another example, you might do one month of General Internal Medicine, two weeks of Cardiology, and two weeks of Nephrology.

Suppose you start on General Medicine. Let’s flesh out a typical day. Bear in mind that every medical school is different and other’s may have had different experiences.

How early should you show up?

Get to the floor early enough to pre-round on the patients you are assigned to follow. This simply means that you must see the patients, examine them, and make a note of any changes in their condition before morning rounds. You must also follow up on pertinent labs or studies from the day before and be familiar with their treatment plan (including the all-important discharge plan) as well as any pending tests and their current medications. How early you show up depends on the number of patients you are following, your familiarity with them, and how efficiently you work.

Keep in mind that you will be waking most of the patients up to do your exam. (Usually a focused exam dealing only with the presenting complaint. You do not generally need to do a neuro exam for someone being treated for a small bowel obstruction.) While they expect to be disturbed during their stay, 4 AM is a little early to be turning on the lights and poking them in the belly. (Examining a patient in the dark is called “groping” and is a no-no.)

You will probably not be assigned more than two patients when you first get started, Still, as you will be completely unfamiliar with almost everything about the workings of the hospital I’d allow plenty of time. If you show up too early the worst that will happen is that you will be standing around with nothing to do before morning rounds. The converse to this is not having enough time and being asked embarrassing questions about your patients that you can’t answer.

Typically, you will be responsible to make a note in the patients chart before rounds summarizing what you have learned. This is the famous “SOAP” note of which you have probably heard. The SOAP note is easy to grasp but difficult, initially, for most medical students to execute. The usual problem is trying to cram too much into the note. It should be concise, not wordy, and should not recapitulate the admission History and Physical except to remind the reader about the patient. (Believe me, the admission H & P, especially on medicine, is where you can go crazy with detail.)

The parts of a SOAP note are as follows:

Subjective: Who the patient is, a brief summary of the reason for their hospitalization, and what they or the nurses told you about their hospital course overnight.

“Mr. Jones is a 63-year-old man admitted for congestive heart failure exacerbation. The patient reported difficulty breathing and a non-productive cough last night at around nine PM but these resolved after administration of IV lasix. Patient is currently without complaints.”

Objective: Subjective is just that, subjective. It does not cover things that you observed in your exam or were reported by the lab, radiology or other consultants. These things are all objective, that is, facts that do not depend on the patient’s interpretation.

Typically you record the last set vital signs making particular note of anything unusual like a fever overnight or a string of high or low blood pressure readings which were unusual for the patient.

Next you will record the results of your physical exam. Generally, every patient regardless of their complaint deserves at least a cardiovascular exam, a lung exam, and an abdominal exam. Listen to the heart in several locations, listen to the lungs, listen for bowel sounds and palpate the abdomen. You can record this succintly using any number of “boiler-plate” abbreviations such as “lungs CTAB” for “lungs clear to auscultation bilaterally.” Of course you need to note any new findings,

Although opinions vary, on my SOAP notes I like to record pertinent lab values. I know that the results are usually on a computer somewhere but it simplifies the job of the person reading your note. I also give brief summary of any new imaging results or the results of any other tests which were not available for the previous note.

assessment/Plan: This is the list of what is wrong with the patient and the ongoing plan to address these problems. Typically it is also preceded by a brief recapitulation of the patient as in the first line of the note. Is this necessary? Maybe not but since most people jump to the assessment and plan when they read a note, particularly a long one, the recapitulation is always helpful. People will read your notes. might as well make them useful and user friendly.

You might say “Mr. Smith is a 63-year-old man with a history of congestive heart failure, Diabetes, hypertension, and gout admitted on January 3rd for a CHF exacerbation.” Then you make a list, by problem, of the plan to address that problem and how things are either working or not working.

For example:

CHF: Patient diuresed of approximately three liters of fluid over last 24 hours on 60 mg IV lasix every eight hours. Chest xray shows continuing resoution of pulmonary edema. Last ejection fraction was 25 percent by transesophageal echo on January 1st.

Diabetes: Well controlled on sliding scale insulin.

Hypertension: Blood pressure well controlled on Hydralzine etc. etc. etc.

You get the point. Also, you might want to add in your note how the patient is doing towards meeting his discharge criteria. Use accepted abbreviations but try not to get too jiggy with them. Most people have to think a little before they realize that BRBPR stands for “Bright Red Blood Per Rectum.”

Why is a the SOAP note important? Several reasons. However, let’s not kid ourselves into thinking that your attending or your resident is going to rely on your assessment and plan for her treatment decisions. Ain’t going to happen. Sorry. What the note does is provide a framework for your over-worked resident to quickly add her own pertinent comments as an addendum to your note. Sometimes the addendum can be as simple as “Agree with medical student note.” At other times the resident will add her own assessment and plan. Either way it saves her a little bit of time.

For you, the medical student, the big advantage of the SOAP note is that if you copy them and carry them around you will be well-armed when the time comes to present your patient.

More on that in Part 2.