Everything I Learned in Medical School: Besides All the Book Stuff (2 page)

Chapter 2

The Switcheroo

Nothing was out of the ordinary as my morning began. The holding area that led to the operating rooms was abuzz. The place exuded that hospital feel, with white walls, white floors, and the smell of various antiseptic cleaning concoctions. Everyone walking around was wearing little blue shoe covers and matching blue hair covers, the type of stuff you see surgeons wearing that make them look like they belong. There were anesthesiologists standing next to patients on stretchers, explaining how they would be put to sleep for their procedures. There were ophthalmologists walking around, getting ready for their next cases or casually chatting with fellow eye doctors. And there I was, the lone medical student, trying to find an interesting surgery to go see. Little did I know that this morning, I would run into the most peculiar patient I had ever seen.

It was my fourth and final year of medical school, and this was my ophthalmology rotation. The entire surgical suite was dedicated to eye surgery. For the entire month, I would follow various doctors and simply watch as they performed intricate surgeries. Frankly, things were getting dull. I had already seen enough cataract surgeries to last me a lifetime. But on the schedule for that day was a case I had not seen before. When the case was about to begin, I walked into the operating room, mask on my face, ready to see something new.

The resident was already in the operating room. He saw me walk in and gave me a quick overview of the patient.

“He’s had an inflammatory reaction in the upper cheeks, bilaterally,” he said, very matter-of-factly. “We’ve got to go in there and break things up a little, because the inflammation has tightened up his cheeks to the point he can’t close his eyes.”

One glance over at the sedated patient on the operating table and I knew something didn’t quite fit. The resident kept making reference to “he” and “his”. Yet the patient clearly had the facial features of a female. High cheekbones. No facial hair in sight. Maybe the resident was just mistaken.

The nurses began performing the mandatory “time out”. This is a safety precaution in which they verify that the patient is indeed the proper patient, and the procedure is the appropriate procedure. As you can imagine, one of the biggest mistakes you can make as a surgeon is operating on the wrong person, performing the wrong operation, or operating on the wrong side, so this part is critical. But even the nurse performing the timeout began with, “
He
is here for bilateral…”

The resident must have seen my confused glances at the patient, so he kindly filled me in. The patient was indeed a male, but with transgender identity disorder. Simply put, he wanted to be a female. So, in order to look more like a female, he had gotten laser surgery on all of his facial hair. In addition, this patient had gotten silicone injections in his buttocks, lips and cheeks. It was the silicone injections in his cheeks that had gone horribly wrong, and the reason he was on the operating table that day.

It was one year earlier when the patient checked into a hotel to participate in a “silicone party”. This was a party in which two guys would inject silicone into whatever body part a participant desired. For their services, they charged a small fee. Unfortunately, these two “plastic surgeons” were not doctors at all, just some guys looking to make a few quick bucks. Many questions are probably going through your head at this point. Why would someone go to a hotel for this procedure? Why would you trust random people to inject a foreign material into your body if you knew they weren’t doctors? What was this person thinking?! All good questions. I have no answers for you.

To make matters worse, the silicone these pseudo-surgeons were injecting was not exactly medical grade silicone. In fact, it was purchased from a local Home Depot. It doesn’t take a medical professional to realize that this is bad news. For this patient, the lip and buttock injections worked just fine. However, the cheeks had developed an inflammatory reaction to the silicone. It was his body’s way of saying, “Tiss, tiss, tiss.” Apparently, this silicone wasn’t meant for direct human injection. Go figure. The ophthalmologist had to dig under the inside of his upper lip, go under both cheeks and up to his eye socket to implant a device to hold his cheeks up. This would allow him to actually shut his eyes. Not the result this patient probably had in mind when signing up for the silicone party.

It is hard to imagine what drives people in their daily decisions. At what point does having an untrained man in a hotel inject silicone into your body seem like an acceptable decision? But then again, we’re all guilty of making choices that others would think were crazy. I decided to go to medical school, which some would consider crazy. Some people decide to smoke. Others may consider driving a motorcycle crazy. It all depends on where we set our “crazy meter”. But when it comes to plastic surgery, everyone should sound their “crazy alarm” at a low setting.

And in case you’re wondering, the rogue, silicone-injecting “plastic surgeons” are now serving a prison sentence.

Chapter 3

The Hierarchy

Imagine an ordinary place of work. Let’s say it’s an office building for an investment banking firm. There are two people standing at the water cooler. One is a mere associate, while the other is the vice-president of the company. Just by looking, it is often hard to tell which is which. Now, let’s pretend we’re walking around in the hospital. Here, figuring out who’s the boss is not so difficult. Imagine that the boss (aka, the attending doctor) now has a cape with fluorescent colors that indicate his superior rank. Along with this is a hat with flashing lights that not so discretely spell out, “I’m your daddy”. And in case you missed both of these, he or she has an entourage of residents and interns that fan him and feed him grapes.

Okay, it may be a little more subtle than this, but it’s obvious that in the hospital, the hierarchy is everywhere, and it’s in your face constantly. For starters, those that are higher ranking have longer coats. Most attendings have white coats that reach their knees. A slightly shorter coat goes to the resident, who is still in training, but far enough out from medical school that they know what they are doing. An even smaller coat is worn by the intern, the title given to an MD during their first year after completing medical school. And no, they don’t know what they’re doing. And then there’s the medical student, whose coat resembles a tight fitting, full-sleeved vest, the kind that makes your arms pull away from your body. In addition to coat length, every doctor has their name clearly written on their coat, along with every degree they’ve ever received. Every now and then, I’ll spot an MD, JD, MPH. If this isn’t enough hierarching (which must be a word), the doctor’s field of expertise is clearly written below the name, which adds yet another level of superiority to those lucky enough to be neurosurgeons and cardiologists.

The totem pole carries over in even the most subtle of actions in the hospital. For example, watching a team of attendings, residents, interns and medical students walk around the hospital is an easy way to quickly decipher who’s who (in case the coat length, embroidered letters indicating degree, and flashing hat weren’t enough). The key is paying attention to the order in which they walk. For those of you interested in medical school, I’ve taken it upon myself to help teach you this order. Below you will find appropriate walking orders. Just for clarification purposes, “1” indicates the person in the lead, “2” is second, and so forth. More than one person next to the number indicates people walking side-by-side. Here we go…

Acceptable walking order:

Attending, senior resident

Intern

Medical students

or…

Attending

Senior Resident, Intern

Medical students

or even…

Attending, senior resident

Intern, medical student (the kiss up one)

Medical student (the nervous one)

The following are unacceptable, and rarely ever seen:

Attending physician, intern

Senior resident, medical students

or…

Intern

Attending, medical students

Resident

and definitely, definitely not…

Medical student

Anyone else

Another situation in which the hierarchy becomes obvious is when an attending tells a joke. First and foremost, if someone on the team tells a joke, you can pretty much say with certainty that this person is the attending. No one else would dare attempt to add humor to the workday. Every so often, the joke will actually be funny, in which case everyone laughs briefly and moves on, not allowing us to determine the rest of the hierarchy. But 9 times out of 10, the joke is not so funny, and that’s when, once again, rank becomes obvious. First, everyone must laugh, it’s required. So, residents, interns, and medical students all begin. The fake laugh in and of itself is hard to master, since it’s usually pretty easy to see through a fake laugh, so this must be practiced. So there is the team, laughing away. Pretty soon, the resident stops laughing, and taking the cue from the resident, the intern soon stops as well. If there is only one medical student, they can stop laughing soon after the intern and life is good. But if there is more than one medical student around, this part starts getting tricky. Each student feels they have to be the last medical student laughing so as to show the attending they thought the joke was funnier than their fellow medical student, thereby obtaining the favor of the attending, and a better evaluation at the end. Unfortunately, at some point, the laughing goes on for so long that it becomes obvious you are faking it. So, for two dueling medical students, it all comes down to who can laugh the longest, but stop right at the time it starts looking fake. This is challenging. Many factors play into how long you can carry on the laugh, such as how convincing you can be (an occasional knee slap never hurts, but more than one knee slap is pushing it), how gullible the attending is (does he actually believe he’s funny?), and the jaded level of the resident (the more jaded, the shorter time the student should laugh, so as not to make residents mad for prolonging the torture of rounds). The combination that worked well for me was a simple head throw (where I throw my head back and laugh into the air for a few seconds), followed by a few head nods as the laughing dies down, and finished off with a, “that’s too funny.”

Hopefully these little walking and laughing lessons will help you easily figure out who’s who in the hospital, not to mention provide useful tips to those aspiring to be physicians. You can thank me later.

But in all seriousness, there has to be a reason that such a hierarchy is so entrenched in the medical world. Is it because it makes it easier for patients to identify the head physicians? Doubt it. Is it because after years of studying and working, doctors feel entitled to some recognition? Possibly. Does it just feel good to be the boss after years of getting bullied as a kid for being the smart one? Probably. But as it turns out, not every attending physician behaves like royalty. In fact, quite a few treat residents as equals, are very approachable for medical students, and seem to really enjoy their work. One soon realizes that the hierarchy-loving, order-spouting attendings often hide behind their rank. Perhaps they are not as comfortable with their knowledge or skills as a physician, causing anxiety which translates into emphasizing their rank on the medical totem pole. So, look for those doctors that walk in the back of the pack, don’t mind when you don’t laugh at their jokes, talk to nurses with respect, say hello to the janitors, and don’t worry about rank. I’ve learned that they are the smart ones.

Chapter 4

I Don’t Even Know You Anymore

History has molded our impression of medicine into that of a noble field. With rare exception, doctors throughout the world are held in high regards. After all, they are deemed to be intelligent, hard working, ethical people, who have dedicated their lives to the welfare of others. They are role models for a healthy lifestyle. We start to believe all of these lies very early in life.

As a child, my parents and I made frequent trips to the pediatrician for my mild asthma problem. There were multiple doctors in this practice, and it never really mattered to me which one I saw. After all, every doctor was smart, capable, and knew exactly what to do. They seemed incredibly honest, trustworthy and confident, making it easy for my parents to place the burden of handling my health concerns on them. Whatever the doctor said, we would do. They seemed like perfect people, with all the answers.

Medical school quickly changed my perception of doctors. The first blow was during a party to celebrate the half-way mark through our first year. We had completed many of our basic science courses, which included anatomy, genetics, physiology and biochemistry. During this time, we had dissected the lungs of cancer patients and learned about the cellular mechanisms that can go awry on the way to developing cancer. There were detailed discussions on genetic predispositions to this terrible disease, and how its risk was multiplied significantly by exposure to compounds such as cigarette smoke. If I hadn’t already decided, these lectures were enough to convince me to stay miles away from cigarettes. Not only that, I was prepared to help stamp out the “cancer stick” amongst my future patients. But despite these lectures and this knowledge, I was surprised to see a group of future doctors proudly puffing away at this party. Somewhere in my brain was a small part that refused to believe doctors, or future doctors, would do this kind of thing, the same way that I refused to believe movie stars had to poop when I was a little kid. These people couldn’t possibly do something so disgusting. And yet I was seeing it first hand (the smoking, that is).

But this was only the beginning. Over the years, there were countless stories of other questionable behaviors that I could not imagine my doctors doing as medical students. Anything from multiple classmates using marijuana, to snorting prescription pain medications, to alcohol abuse, and even close associations with exotic dancers, we had it all. There were stories of debauchery between students and our superiors, unstable cases of depression and anxiety, as well as, trouble with the law. The revelation that these future physicians were far from perfect with their own health and well-being was frightening. How would we hold our patients to a higher standard when we couldn’t even manage our own health?

But then again, perhaps the mold that doctors are expected to fit is a bit unfair. Does it matter what vices a physician deals with so long as it does not impact patient care? I must admit, I did not figure out an answer to this. What I did learn is that doctors and future doctors have the same problems everyone else does. Going to medical school doesn’t grant you a “get-out-of-problems-free” card. Having in-depth knowledge about the risks of smoking and drugs does not shield you from their allure. Because as it turns out, everyone poops.