Doctors in training
DOCTORS IN TRAINING: Top-down experience
On August 12, 2017 | 1 Comments

Doctors In Training: The Pecking Order

After the first two medical school years of only classroom and lab work, a medical student begins his/her clinical rotations in the hospital. There’s both excitement and anticipation as you find out which specialty you’ll begin with. My first clinical rotation, Obstetrics-Gynecology, was at Howard University Hospital (HUH) in Washington, D.C.

Doctors in training: Howard University Hospital

Howard University Hospital

 

 

Students were paired up and remained partnered until the end of the rotation. If you didn’t like your colleague, you were stuck. Before we paired off, however, we all observed a live delivery. One of the tallest, strongest, jockiest guys, who had played football in college, immediately fainted while witnessing the birth. That was my first lesson that it’s the most macho guys who invariably faint at the sight of a little blood or procedure–reliably true to this day.

The hierarchy for doctors in training is clear from the beginning. The medical student is at the bottom. He or she may be used for anything from running blood, sputum, spinal fluid (and worse) to wheeling a patient down to the x-ray department or going on a pizza run. Pizza tastes especially good at 3 AM while you’re on duty. Next after the med student is the intern, who does a lot of scut work as well, but is often responsible for the bulk of the medical histories and exams of the patients admitted to the team. There may be one, two or three interns on the team. The 2nd-year resident has completed his/her internship and has confidence to supervise the interns. The 3rd-year resident is of course more experienced than the whole bunch, and a lot of the time can get a little cocky, having survived two years of baptism by fire. The 3rd-year supervises everyone and must be ready to defend his or her juniors during rounds. He or she is often cruising through the lighter specialties for the final year, having a relatively relaxing time and actually getting home at a decent hour. In longer residencies like General Surgery, which can be 5 years, there will also be 4th- and 5th-year residents. The chief resident, as you can guess by the name, is the boss of all the residents and is supposed to liase with them and the directors of the residency program. He or she usually has exceptional smarts and clinical skills. I remember when I was a medical student, I thought the chief residents walked on water. Above all of the residents are the faculty and attending physicians and the head of the department.

After completing med school at HUH, I moved to southern California to start an internship in Internal Medicine at Martin Luther King Hospital in the Willowbrook area of south LA.

MLK Hospital, ideal for doctors in training (Photo:hmcarchitects.com) 

Present modern facade of MLK Hospital, ideal for doctors in training (Photo:hmcarchitects.com)

 

Doctors in training must endure rounds . . . and more rounds

There are all kinds of “rounds” for doctors in training. You’ll round till you’re sick to death of rounds. They are any form of meeting between medical professionals to discuss cases. After every admission night, there are usually intake rounds (sometimes called morning conference/report) wherein new and/or complicated admissions are discussed with the chief of staff or program director, senior physicians, chief and senior residents.

Morning report: staff and doctors in training in the Pediatrics Dept at Vanderbilt University School of Medicine (Photo: Vanderbilt University)

Morning report: staff and doctors in training in the Pediatrics Dept at Vanderbilt University    School of Medicine (Photo: Vanderbilt University)

 

 

Thereafter the teams split up for their respective attending rounds headed by an assigned attending physician, who will listen to the accounts of the new cases, examine the patients, do some teaching for the benefit of the doctors in training and medical students, and make suggestions for diagnostic workups and treatment.

The team may be small, depending on the size of the residency program and the specialty as shown here:

Bedside rounds: smaller team with attending and doctors in training

Bedside rounds: smaller team with attending physician demonstrating a physical sign to the doctors in training and medical student (Photo: Abbott Northwestern Hospital)

 

 

The team may be larger and include nurses, allied healthcare professionals such as respiratory therapists, nutritionists, and social workers.

Hospital rounds with a larger team of the attending (Dr. Carmelo Graffagnino, right,) and doctors in training (Photo: Duke University)

Hospital rounds at Duke University Hospital with a larger team of the attending (Dr. Carmelo Graffagnino, right,) and doctors in training (Photo: Duke University)

 

 

The medical students (circled) are recognizable either by their short white jackets or simply looking younger than everyone else.

 

The art of the medical history & physical exam (“H&P”)

The intern and/or the 2nd-year resident, sometimes the 3rd-year as well, “present” the cases to the attending physician. In general, the narrative should follow a stylized pattern that all doctors in training must master.

  1. Chief complaint: the problem that made the patient seek attention or to be brought to medical care, e.g. chest pain, cough, headache, weakness, dizziness, etc.
  2. The present history: the story of the illness related to the chief complaint, including signs and symptoms, starting with the words: “This is a 70-year-old man/woman/male/female who came in for . . . “
  3. Previous medical history and past illness, if any.
  4. Previous surgical history, if any.
  5. Relevant family history, if any.
  6. Medications taken, including prescribed and over-the-counter.
  7. Allergies to anything, if any.
  8. Physical exam with vital signs, i.e. blood pressure, temperature, heart rate, respiratory rate; some authorities recommend adding the pain level (the patient’s, not yours); pertinent positive findings (what the patient has, e.g. an abnormal heart rhythm); and pertinent negatives (what the patient does not have, e.g. swelling of the lymph nodes)
  9. Laboratory findings so far–some may not be ready until several hours, days, or even weeks.

Attending physicians can get persnickety about the way doctors in training deliver the history narrative (Image: doccartoon.blogspot.com)

Obviously, such a case presentation can take quite a bit of time. The skill is to present it clearly and concisely and not put everyone to sleep by droning on about unimportant issues. Medical students and interns fresh on the wards tend to give long drawn out presentations while the more seasoned residents squirm inwardly and pray for a more speedy narrative. After the presentation, the attending may have a few questions before going with the team into the patient’s room to talk to him or her, examine him or her, and possibly teach all the doctors in training techniques or significant physical signs present. Now imagine going through the same process with anything from five to fifteen new patients and you could be rounding for hours. Many attendings are very helpful in speeding up the process and often at the end of rounds you feel you’ve learned a lot in a short time.

 

Dealing with a heavy patient load

Depending on the number of patients a team admits to its service on sequential admission days or nights and how many preexisting patients have been discharged or otherwise sent elsewhere, the number of patients carried by the team can become overwhelming. The third-year resident, if he or she is on top of it, will help the residents and interns thin out the patient census on the service as quickly as possible and by whatever means available.

Doctors in training: the overriding goal is to discharge as many patients by whatever means possible (Image:cartoonstock.com)

In my residency, one technique of cutting down the patient load was turfing, i.e., getting a patient transferred to someone else’s turf (specialty, floor, or ward) or even another hospital. For example, if you admitted a patient with kidney failure, you would want to turf him or her to the renal ward, or someone with a life-threatening illness may need to go to the ICU. I had a 3rd-year resident who always said, “Don’t talk to me about interesting medical cases. An interesting case is one we can turf to the VA [Veterans’ Administration] Hospital.” We did admit quite a few veterans.

Mind you, turfing is often in the best interest of the patient as well and isn’t necessarily a selfish act by the team. Nevertheless, there are often “turf wars,” in which the tentative receiving service may be resistant to accepting a patient from the transferring service. At times, there are furious arguments as to whether the transfer has merit. Politically well-connected and/or popular residents often win the turf wars. For example, if the chief resident says a patient must be moved elsewhere, it’s going to happen tout de suite. It’s in anyone’s interest to cozy up to the chief resident. Unfortunately I didn’t cozy up to anyone during my residency.

The problem with ward rounds and teaching rounds the morning after a long night of new patient admissions to the service is there is a lot of work waiting to be done while rounds are proceeding–workups, diagnoses, and treatment. If ward rounds go into lunchtime, it leaves only the afternoon to do a bunch of stuff before you get to go home for some sleep. When I was a medical student on the General Surgery service, the residents complained bitterly about all the time the attendings spent quizzing and teaching the students on morning rounds.

 

Pimp sessions

I did my internship at MLK  Hospital (see above) where rounds were quite lowkey. But when I moved to the ginormous Los Angeles County University of Southern California General Hospital (or LAC-USC Medical Center), at the time the largest teaching hospital in the US, it was a different story.

LAC-USC General Hospital: iconic building and second home to thousands of doctors in training

The old LAC-USC General Hospital: iconic building and second home to thousands of doctors in training and the image used on the long running soap General Hospital (Photo: physiciansnewsnetwork.com)

Still home to thousands of doctors in training, the newer LAC-USC, foreground, older building background (Photo by Downtowngal)

Still home to thousands of doctors in training, the newer LAC-USC, foreground, older building in background (Photo by Downtowngal)

Attending rounds earned some unpleasant apellations, e.g.  such as “pimping” or “firing squad.” Actually I was never sure “pimping” is the right characterization, but it probably referred to the bullying and humilation that could occur on rounds. It could be that there’s a kinder, gentler approach now (it’s been quite a while since I’ve been on medical rounds in a teaching hospital, so I may need some updating on what it’s like at present) but historically attending/ward rounds could be quite stressful if the attending physician(s) and sometimes the senior/chief resident(s) pounced on an intern or second-year resident with very difficult questions either about the disease process of a patient, obscure medical syndromes, or any aspect of the H&P that was lacking. I found the environment at LAC-USC was very much about one-upmanship, flashy displays of knowledge, and putting others down. It’s perhaps unsurprising in a place with very brainy, competitive people. That in itself isn’t bad. What’s bad is the appearance of deliberately trying to dominate or embarrass medical students and doctors in training by stumping them in front of a team of several people, and then chastising them for not displaying encyclopedic knowledge. Nevertheless, I have to say that the tough lessons learned from being humiliated became seared in my memory and served me well when I got into practice. So was “pimping” a good thing? I think it’s the way you take it as an individual. The more you can shrug it off, the better. I didn’t shrug off my humilations too well.

 

The mother of them all: Grand Rounds

Grand Rounds are pretty much what their description is: grand. It’s a big deal with a large meeting of several disciplines. Often a challenging and baffling medical case is presented and a guest speaker or panel of brainy specialists will discuss it back and forth. They’re pretty enjoyable and can be funny at times. Serious doctors often have a surprising and wry sense of humor, particularly the ones who have been around for quite a while. Sometimes you shake your head in amazement at how brilliant the expert or guest physicians can be. At some Grand Rounds, they give their best guess before the final diagnosis (if available) is revealed to them.

Grand rounds at Jackson Memorial Hospital with the big shots at the left, physician staff, doctors in training, ancillary staff (Photo: @Surgeon_General 2016)

Grand rounds at Jackson Memorial Hospital with the big shots (left), physician staff, doctors in training, ancillary staff, medical students, etc. (Photo: @Surgeon_General 2016)

 

There’s a lot of learning packed into the 3+ years of residency. In my next blog, I’ll talk about what it’s really like on a night-on-duty from hell.

 

Comments1
Betty Tyler Posted August 13, 2017 at2:03 pm   Reply

Most enlightening. Thank you.

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