Food Chain

Medical student : plankton :: attending physician : Great White shark

And I guess resident physicians would be...barracudas?

Medical school is 4 years. You get your M.D. and then train some more in residency, where you are called a resident. Your first year in residency is called your intern year, and you are called an intern. All interns do the same thing no matter what field you want to go into. They take care of the patients in the hospital, making phone calls, calling consults, nagging the nurses, and writing notes in the charts. Sometimes they have to go to clinic to see patients, which they hate (especially the surgery interns, who prefer their patients anesthetized).

When you are a third year medical student as I am, you are the bottom of the totem pole. Nobody is below you on the ladder. Even the lady sweeping the floors knows more about the hospital than you do, at least geographically. The nurses know the protocols better than you. The attendings know the medicine better than you, and half the time you are terrified of them. The interns are so damn happy to not be at the bottom (though they are only one rung up) and are generally kind to the students.

The residents are the wild cards on the medical team. Some residents love to teach and help students learn. We looove this kind of resident.

Other residents are like the overlords. They feel they are getting some knowledge under their belts, and love bossing the interns around. They also love to lecture medical students in the most irritating pedantic fashion. This is my new resident, and needless to say, he sucks.

Yesterday we saw a patient together--a new medical admission from the clinics downstairs. He told me before we went in that he had only 20 minutes to talk to the patient and do the physical exam, and that he wanted me to do it. Fine, although 20 minutes is not really sufficient, but I get it, he's busy. I went along and asked the man the typical questions--where does it hurt? when did it start? how did it feel? how long did it last? have you had this before? did you take anything for it? what makes it better/worse? I also asked him questions about his past medical history and family history, since this patient was new to me and I didn't know anything about him yet.

After we took the history, my resident was checking his watch and looking annoyed, so instead of completing the physical head-to-toe as I normally would, I just rolled up the guy's pants leg to look at his leg (he had a possible blood clot). I figured the resident could get the info he needed to start his admission note and that I would come back later and get a more detailed physical and history.

Later my resident took me aside and the lecturing began. "Your history was a little too detailed; you don't need to ask too many questions here. We know what's going on, so don't bother asking about family history right now. We don't care about that." Hmm. News to me. I read that 80% of medical diagnoses can be made from history alone. And many important medical problems are related to family history. Since when is that unimportant?

"And furthermore, your physical exam should be more systematic. You need to go head-to-toe. Don't just jump to the leg right away." Ok dude. If you weren't breathing down my neck, glancing at your watch and shifting your weight from foot to foot for the last 10 minutes I wouldn't have felt pressured to skip half the exam. "And I didn't see you check for Homan's sign, so go back and do that later."

In patients with blood clots in the calf, they can have pain when you push their foot up towards their knee (so their toes point to the ceiling). This is called a positive Homan's sign. Unfortunately the sign is practically meaningless; you can have a clot and not have the sign, and you can have the sign and have no clot, and it doesn't help at all.

So I went back and did the Homan's sign, being an obedient medical student. I reported a positive Homan's sign this morning to my attending physician, to whom I must present the new admissions during rounds with the team. "You did a Homan's?! You know you can dislodge the clot by doing that maneuver..." Dislodging a leg clot can cause it to float through the veins back into the right side of the heart and into the lungs, meaning pulmonary embolism and possible death for the patient.

Thanks, resident!