Thursday, June 29, 2006

Intern's Lie

I’m drawing a blank. In these instances, I have learned, the optimal solution is to post something you’ve written in the past. I wrote this in the beginning of my second year of residency. Looking back I realize it’s kind of immature, but, right on the money!

Tomorrow, 7 am sharp, I embark on a new journey. I will be head of the team. This team will encompase one Attending, one Resident (that is I), two Interns (first year residents), one Sub-Intern/ fourth year med-student (from here on the “Sub-I”), and two third year med-students (a.k.a. “Students”).

To serve the readership yet unfamiliar with the medical hierarchy that governs today’s fine medical establishments I will now take the time to explain this stepladder of ass-slurpers. The understanding of this is essential for our future relationship and so if you have any questions feel free to ask.

I will comprise the list to range from least kissed ass to practically dripping. Remember, each member of the team has a primary goal, a secondary goal (if applicable), friends and enemies. It is long; I am sorry for this, but essential for the upcoming month. Let us begin:

1- The Students/ Third Year Med-School

Primary goal: To impress Attending and Resident with knowledge we were sure they never had. Secondary goals: To cloud a simple clinical scenario by suggesting that the patient has as many extremely rare diseases as possible, to name a disease the Resident hasn’t heard of and to send out for as many of the most expensive blood tests we have as the Resident allows. The sub-I is their best friend as he is closer to the resident and is always up to date on their performance thus far. Enemy: Interestingly enough, they are each other’s enemy as they are always being judged comparatively to each other. This undercurrent of hate is masked very well and only a thorough Freudian understanding of the subconscious can uncover it.

2- The Sub-I

Primary goal: Impress attending, Sub-I’s need recommendation letters for the residency match so they too can be taken advantage of by residency programs and government. Secondary goal: Discharge patients, less patients mean less work and try not to sound like Student by naming any rare disease.

The Sub-I’s friends are the Intern and the Resident, possibly third year but only if they agree to do his blood draws. Enemy: Patients with extremely rare diseases (makes Sub-I extremely uncomfortable as he now has to sound like Student).

3- Intern

Primary goal: Discharge patients. Intern will do or say anything to achieve this goal as he/she is usually overworked and would love to have one less family and upcoming tragedy to deal with. Secondary goal: Anything that ends in less patients (I cannot stress this enough).

Their friends are the other interns, amazing bonus point if able to really swing Resident to their “point of view” (often wrong!). Enemies: Patients!!!!
4- Resident (my new position)

Primary goal: To impress Attending and Chief of Medicine while also keeping Intern happy, motivated and feeling that Resident is truly on his side. Secondary goal: Constantly remember that Interns LIE! Again, they do anything to get patients out and Resident must continually double check Intern behind Intern’s back as INTERNS LIE! Friends: The Attending and other Residents. Enemies: Everyone on a certain level: as Interns LIE, Sub-I wants information primarily for Student, Student wants to name rare disease and make Resident look bad. To counteract Student, Resident must immediately say “I don’t know that but why don’t you give us a presentation on this tomorrow morning” (Gotcha Ya Bastard!).

5- Attending Doctor

Primary goal: Come for 2 hours in morning, teach, and leave as fast as possible, keep name out of chart so no one knows who to sue later. No Secondary goal. Friend: All. Enemy: No one. Remain completely oblivious to the ass smooching going on a round you. Wipe ass off after morning round.

6- Chief of Medicine

Primary Goal: Teach and run Medicine Department. Secondary goal: Absorb all ass-kissing, taking it all in as one continuous lick that lasts for many years. Secondary goal: Try to remain seemingly very humble, once in while give a lecture which makes every resident in the room feel like he knows absolutely nothing/ give up his medical license and go back to medical school.

This is the system within which we all operate. If there are any questions please feel free to ask. Tomorrow, I will do my best to avoid all questions and appease Intern to join my view of things. This will be my greatest chess match yet.

363 Comments:

Anonymous emmy said...

Well now, this does explain a lot. I hope you don't mind if I print it out and keep a copy of it in my wallet. Next time I have the misfortune of ending up in the hospital maybe I'll be able to figure out who everyone is.

11:40 AM  
Blogger Kelly said...

This is my all-time favorite post of yours!

I couldn't for the life of me figure out why my daughter's doctor was always surrounded by what I call "ducklings", every time he walked into our hospital room. This piece was a HUGE eye opener! Oh, and not to mention terribly funny. I even emailed it to that doctor, hoping he'd get the kick out of it that I did...

....with the disclaimer that I didn't feel he lived up to this example of an Attending....

But then again, a resident or intern, I ain't, so who knows?

But you did leave out "Fellow" which totally screwed me up later, when I had a gaggle of surgery fellows crowding our bedside one time.

Either way, thanks for the insight!

12:59 PM  
Blogger QCOMDRJ said...

Freaking. Awesome.

I get to start being a sub-I on Tuesday. Hope I can do you proud.

8:38 PM  
Blogger Dr. A said...

This is SO money! Hilarious and TRUE!

12:48 PM  
Anonymous Anonymous said...

Say, is there anyone on the team who doean't hate patients? Or does everyone hate patients on an equal basis?

Makes you wonder why any of these 'team members' wanted to become doctors in the first place.

2:04 PM  
Anonymous Anonymous said...

In my experience, the best "doctors" on the team are the med students (3rd year).

They take the most time to answer our questions, they seem to care more about the patients than the other docs do. I realize that the med students dont follow as many patients, so they are not as busy as the other docs.

Whenever I or someone I know has been to the hospital, the med students have been outstanding. They dont always know the answers to questions we have, because they dont have authority to tell us when we can leave or whatever, but the time they take to talk to families makes a big difference

6:30 AM  
Anonymous Anonymous said...

Hi I am a med student and about to start 3rd year..... i have some quetions and comments for the more senior people:

1) Do my SOAP notes count for anything, or does the rest of the team just ignore it? I notice that both my intern and myself write SOAP progress notes.

2) At our school, we have a weird system. The attending in charge of the patient is not at rounds. The med students make an oral presentation to the residents, other med students, and subIs, and pharmacists who round with us, but there is no attending in sight.

3) We have "teaching" attendings who are totally separate than the attendings who are in charge of the patient. The "teaching" attendings ask us to present our patients, and they we go to the bedside and do some physical exam stuff and discuss diff dx. HOwever, for these "teaching attending" roudns there are no residents present, and the teaching attending is NOT responsible for hte patient's care.

4) The attending in charge of each patient seems to live in their own little universe. They dont come to rounds. They round on their own patients at random times, totally separate from the rest of the team. In fact for my patients I have never seen the attending. They leave their notes in the chart at weird times when nobody else is around, and are nowhere to be found otherwise. The only contact I have with the attending is thru reading his written notes in teh chart. The attending schedule seems totally random to me. Sometimes they round their patient at 3 PM, other times its 9 PM at night. And they dont tell us when they are coming to see their patients.

5) On my service, its really the intern that directs patient care. They make all the orders, they cosign any orders that the med students want to do. Of course the attending and chief resident can overrule them, but from a day to day aspect for all practical purposes they are the patient's "doctor"

6) I'm at a very highly ranked hospital and med school, but I think the structure is not conducive to the best medicine. First off, our attendings should be rounding with us at the same time every day, not coming in whenever they want. I have dealt with many angry families who want to know why they never see the attending. I cant even tell them a specific time that the attending will come by. They have to guess what time the attending comes and stumble into them by blind luck.

7) My service is peds, so families play a more prominent role than usual. If there's a 5 year old boy on our service, his parents should be notified of a regular schedule every day when they can speak to the attending, chief resident, or intern. As it stands now, family members have to hang out at the hospital 24/7 and wait for one of the team members to come by.

8) OUr current setup is favored to the medical team with no real consideration for the family. As a result, from the patient's perspective everything seems chaotic and confused. They arent sure who is in charge, there seem to be 20 doctors involved, each with their own plan of action. I'm frankly surprised their arent more lawsuits, because research shows that poor communication and chaotic delivery of care is a major predictor of lawsuit risk. I think the overall patient care here is excellent, but the medical team should be more accomodating to family members

6:47 AM  
Anonymous Anonymous said...

One more question from the med student:

If we are working the night service, and admit a new patient to the service, we do the admission H&P writeup and stick it into the chart.

Is it customary for the night med student to present hte patient at morning rounds? Or are we supposed to hand it off to another med student who comes in for hte day shift?

6:54 AM  
Blogger Internal Medicine Doctor said...

Emmy: LOL, you're welcome. I do agree though, there is no real way for patients to understand the team and how it works. they always seem so confused ("who is my real doctor?")

Kelly: I guess you're right, I did leave out fellow. maybe I have a subconcience loathe for fellows.

justin: just don't name anything rare. you'll be a good sub-I

Anonymous 1: nobody "hates" patients but I can see how you would arrive at that misunderstanding. What we hate is the work that comes along with patients. just like anyone else in the world hates more work. remember, we're human too!

anonymous 2: that's why we keep these students around you know, they're really great for getting to know the patients and, once in a while, they do come up with something spectacular. don't blame the other residents though, it's the system that's broken.

anonymous 3: you'r facility is a bit strange in it's structure for teaching. I've heard of two seperate attendings and sometimes that could be great because the teaching attendings usually have more time. usually, however, the attending on the case meets the other team members and discusses things over, if not for anything then just to make sure everyone is on the same page. and BTW, I love to read students notes because they are usually so thorough. so, keep this in mind, the good docs do actually read your noted. but just so you don't undermine yourself and your intern: make sure you tell you're intern or resident anything in your note or about your patient that you found out that they may not know about.

I also suggest you approach your medical school with these concerns as most of them are certainly valid.

****if anyone leaves and anonymous comment please leave a first name or anything else that you can be identified by ("anonymous 14" just gets a little annoying, and impersonal)

7:39 AM  
Anonymous Anonymous said...

love this post: so true
thanks for reposting
keep it up

9:29 AM  
Blogger ericales said...

In my experience the interns are primarily there for what I like to refer to as fact finding missions. Everytime we are at the hospital (son is post-transplant so this is fairly often) within the first 24 hours at least to interns show up to go over our son's whole medical history. Everyone else should already be aware of things and it usually happens at least twice, but they always come back.

5:45 PM  
Blogger Sid Schwab said...

To the anonymous med student: I'm guessing when you get to a surgery rotation, you'll find things are quite different, and the care plan comes definitely from top down. And the patient will clearly be able to identify and identify with the one who operated, or will be operating. And you will be left to figure out if the one way is better than the other. And I'm not saying.

9:05 PM  
Anonymous Anon 2:14 said...

I'm Anon 2:14 who wrote the comment about 'interns and others hating patients'. I can understand how an intern can hate the long hours, pressure, paperwork and confusion of their work. But patients aren't the cause of this set-up. They're caught up in these confusing situations from a different perspective. And they're an easy target for an intern's (or doctor's) frustrations. I realize what you wrote is sarcasm, but methinks there's a kernel of truth in your story.

2:18 PM  
Anonymous Jon Mikel, M.D. said...

Funny but true... in Mexico things are the same

11:27 PM  
Blogger girl MD said...

just discovered your blog. love the post.
i guess the only thing i can say is that i am truly grateful for my med school (small, minimal to non-existant hierarchy) and my residency program. i've been in small programs, which makes a difference. i'm also in pediatrics, which makes a HUGE difference. family-centered care really does exist.
this is the stuff that t.v. shows are made of...

9:56 PM  
Anonymous Anonymous said...

FYI...I know hospitals like the back of my hand..I NEVER..NEVER..NEVER listen to anyone but THE doctor..let me tell you as a parent of a child who has spent way to many days in hospitals...residents are to be seen and not heard...I have never been so scared as I was the first time I encountered a resident at 4:00am with my tiny baby...he totally blew me away with information and then said well another doctor will be in in the morning I'm sure I have probably confused you totally by now..and he used the word transplant in the information he gave..the word transplant which involves a 4 week old baby will scare the shit out of a mom...when a resident enters my room now I just nod and ignore them....I know more about my childs disease than they do..and please check labs before you come in..at least know something useful..I just want the numbers and surly they can read them right.
I know everyone has to learn but please if you don't know something dont try to fill me full of shit just to sound smart..I already know better.

9:01 PM  
Anonymous Anonymous said...

It is interesting to hear that after 28 years (when I was an intern), absolutely nothing has changed. Medicine has certainly progressed technologically, but there has been there has been no progress in the way physicians look at the rest of the world and at each other. The failure of medical education to change and improve with time is to blame. The attendings and the chiefs had better pay more attention to what's going on.

7:28 AM  
Blogger M. Dyspnea said...

Thanks for taking the time to write that. I can't tell if it's funny or terrifying. I can tell you that I'm laughing nervously. Keep writing, topher.

9:30 AM  
Blogger Michael Rack, MD said...

To the anonymous who asked if everyone hates patients:
Internship and to some extent residency are primarily inpatient. Not all of us doctors enjoy inpatient medicine or are good at it. I hated my internship. I dislike inpatient medicine, and I had trouble keeping the huge patient list organized. Outpatient medicine is a whole different animal.

7:38 AM  
Blogger --Sunrise-- said...

"Secondary goal: Absorb all ass-kissing, taking it all in as one continuous lick that lasts for many years. Secondary goal: Try to remain seemingly very humble, once in while give a lecture which makes every resident in the room feel like he knows absolutely nothing/ give up his medical license and go back to medical school." - ROFL!! Hilarious! :D (btw, came here blog-hopping!)

8:23 AM  
Anonymous NCHD Blog said...

I'm an intern from Ireland and I stumbled across this post thanks to Google Blogs Search and I found myself laughing out loud at it's oh-so-painfully acurate description of the caste like hierarchal system we work under. Bravo.

1:57 PM  
Blogger angrynhsdoctor said...

excellent blog. enjoyed readig it

5:42 PM  
Anonymous 3rd year med student said...

hi, i'm actually a 3rd year med student and i laugh so hard when i read this 'cause IT'S SO TRUE! great post, i'll keep reading this, maybe i'll learn more things of this weird world of medicine that i'm just starting to know

10:09 AM  
Blogger perazhagi said...

interesting post. in a team, the patient just becomes 'work'. not really a person in pain who needs their suffering eased. they are just more work. still...the teamwork largely removes the stress involved in dealing with sick people day in and day out. i used to miss those large teams when in smaller hospital with just an intern and a registrar in a team. less people to stimulate and share heroic or dull moments in medicine. we need to keep the team....but how do we make it more patient focussed...more human...with an individual feel...rather than a mechanical 'work' feel. after all, medicine is about human beings and the emotions when they are in distress. how does the team make the patient feel special and important. i think that is something that we need to figure and learn.

3:07 AM  
Blogger Irishdoc said...

The truth is so painful. One of the best posts around. But beware, I'm an Intern. I LIE.

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Anonymous Anonymous said...

Wow, what an impressively bad paraphrasing of several sections of "House of God".

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Blogger Barbados Butterfly said...

Merry Christmas, Doc. Wherever you are and whatever you're doing now I hope you're smiling broadly. Best wishes to you and Future Intern.

5:02 PM  
Anonymous Anonymous said...

are you really an intern. I really would like to know about your life, because I want to be a doctor. do you watch greys anatomy. Is your life anything like that? email to me at martuletta@yahoo.com

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Anonymous Anonymous said...

I just found you. Enjoyed a few of your posts.
My name is H. I graduated in 05 but took time off to care for my mother who later died. She was poor and I was her caregiver. Alas, I was 5 years too late.

I am now ready to go back. I am volunteering at a local hospital and studying my buns off to relearn all those years of minutia. I plan on applying to all of the IM, FP, and ER spots in my area.

I want some free advice! Can you give me some advice on what to say in letters and interviews. Do I even have a chance? What would you think of a prospect like me crossing your path? Dont hold back!

Thank you

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5:22 PM  
Blogger SPC said...

I almost have to think that you are http://ahyesmedschool.blogspot.com/
all grown up. I have been waiting for this new MD to start another blog.
Almost the same humor but with a more mature understanding.

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Blogger david said...

Hi I am currently a third year medical resident. Will be moving to Louisiana for fellowship. I did my medical school in Israel and was looking into moving there to practice medicine. I thought I might ask you since you said you were going to ultimately move there in one of your posts. How can I reach you?" my email is biggest_leonard@yahoo.ca in case you are willing to discuss this further. Thanks,
David

12:47 PM  
Anonymous Anonymous said...

You WILL live to REGRET working as an Internist in the "Real World."

Think twice, and do some real world research on how happy working internists are, especially working female internists.

You will get real tired of sticking fingers in you know what places and acting as a psychiatrist because they want to have you listen to their woes in life.

Bottom line is all you want to do is practice medicine, but you will not be allowed to do just that, TRUST ME..

THINK AGAIN, before it is too late.

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