So in a week I start 4th year, and I’m debating whether or not to do Radiology first, or switch it out for ENT (ear/nose/throat surgery). Youtube is a fantastic resource for budding young surgeons, as you can watch whole surgeries from the comfort of the home. Bonus: you don’t have to stand in the back of the OR looking bored!

Let me talk you through my thought process. As a quick warning, none of the links in this post are safe for children. Or adults. Or really anybody, including doctors. I’m not sure I can do ENT any more.

Zac (thinking): I wonder if I should look in to some sort of surgical field again? Honestly, I like procedures a lot. What about Urology? Nah, I don’t really want to stick my fingers up dudes’ butts all day long.
Another Med Student: Hey, man, look in to ENT! They do some really cool procedures.
Zac: Cool… lets just go ahead and YouTube some ENT stuff… lets see, this’ll do. Endoscopic Dacrocystorhinostomy.

Hey, nice nose, man. They do this while the patient is awake? That’s pretty cool, you can do it in-office. Neat-o, this is a pretty nifty, delicate procedure. Wait… wait, he’s using a “chisel”? And the guy is awake? He’s going to chisel through his nose while he’s AWAKE? Oh, god, you can hear the bone breaking. Huh, that’s kinda neat, though, he just removed all that bone and now there’s a “sac” protruding. Wait, wait, wait… he’s cutting open the sac. Oh, no - please no - now there’s stuff draining EVERYWHERE… ugh, it looks like it’s all going down the patient’s throat. I think I’m going to vomit.

Zac (nauseated): OK, ok, I can do this. That was just one surgery. How about this one… Nasolabial Cyst Excision.

Hm, that’s funny, that guy has really terrible teeth. Surgeon is getting ready to cut… nice incision, doc, strong wor- WHAT THE FUCK, WHAT THE FUCK IS THAT OH MY GOD ITS ALL DRAINING TOWARDS HIS THROAT!!!! THE IMAGE HAS SEARED ITSELF INTO MY BRAIN AND I WILL NEVER GET IT OUT… OH SWEET JESUS THAT MAN JUST SWALLOWED PUS EVERYWHERE OH GOD THE SURGEON IS MILKING THAT STUFF OUT LIKE ITS A COWS UDDER

A few days ago our office’s nurse cornered me “Zac, I don’t know what to do about the patient over in room 2. She was diagnosed with an ammonia over at the urgent care yesterday and was sent home… she just told me she’s having trouble walking, has difficulty breathing, feels nauseated, and has a horrible headache. Dr. S is in with another patient so I figured I’d ask you if you think we need to get him in there right away.”

Now, hyperammonemia is no laughing matter. Especially when it presents with gait problems, vomiting, and a headache you start to worry about all sorts of stuff, including alcohol withdrawal, drug overdoses, and liver diseases. Warning bells were going off in my head; I asked the nurse if the patient was a drinker; lo and behold, she was.

Rather than seeing my other patient, I waited outside the room for Dr. S so as not to miss him. I gave him the brief synopsis, and he dropped what he was doing immediately to walk over to room 2.

As we entered the room, he started smiling. The patient was sniffling a bit but looked just fine otherwise. She was 62 with a walker.

Dr. S: So they diagnosed you with a pneumonia at urgent care, huh?
Patient: Yep, that’s what I told your nice nurse.

Well, it’s struck again, the dreaded apathy.

It’s interesting, as I look back through my med school career. At first I remember being totally excited to learn, to understand, to really study our coursework. Anatomy, neurology, physiology… that was the stuff I loved in college, and being able to study it and apply it to other people? What an honor, what a privilege!

The grind slowly caught up with me. I studied too much, took the “work hard, play hard” mantra too much to heart. I would sit on the couch with a beer, a sleeping pill, the TV blaring, and my computer fired up simultaneously just to relax. I started making jokes that I used coffee as an upper in the morning and beer as a downer at night… but I wasn’t joking.

I finished Boards - god knows how - and thought to myself finally the long hours, the stress, the constant feeling that I should be doing something productive would stop.

3rd year rolls around and you realize that for all the studying you may have done during years 1 and 2, you still don’t know shit. Attendings pimp you on arcane knowledge from their specialty they’ve been practicing for 40 years and are shocked when you don’t know it. End-of-rotation exams are brutally hard and require you to diagnose, treat, and manage 100 patients in about 120 minutes.

On top of it all is the knowledge that everyone you work with… interns, residents, attendings… are all going to grade you subjectively on how well they thought you did. So you put on your smiley face, pretend like ophthalmology is the most awesome field EVER and go to work every morning, starting on average at 6AM and finishing around 5PM.

It is brutal, and exhausting, and sometimes honestly I wonder if it wasn’t a huge mistake to go to medical school. I’m not asking for sympathy here, by the way, but instead hoping that some of you nod to yourselves while reading this and go “yeah, I know where he’s coming from. I’ve thought the same thing to myself from time to time”.

Listen, sometimes you get that patient who comes along and just makes it all worthwhile. But sometimes you punish your body, mind, and soul for some asshole who treats you like crap and expects you to FIX EVERYTHING WRONG WITH ME even though he’s not fixable.

I’m a person too, folks. I like sleep, and food, and friends, and family. I’ve lost a lot of that these past 3 years… and sometimes the field of medicine just isn’t rewarding enough to make the sacrifice worthwhile.

I suppose the reason I write this now is that I have really, really been enjoying internal medicine- I like the diagnosis, the management, the primary care aspect. But I see my interns and residents getting no sleep every 5th day (and if you aren’t a meddie, imagine that for just one second. No sleep every 5th day for the next 4 years of your life… plus little sleep the rest of the time) and frankly, I don’t know if I want to do it.

So, here I am again, thinking about the decision between doing what I love and doing something where the lifestyle doesn’t suck. There’s a damn good reason people go into pathology, anesthesia, radiology, and dermatology. You work real people hours, and you get paid a decent salary.

After all this time and energy, don’t you think we deserve that?

Figure 1: A foolproof analysis of health vs. hospital stay.

As is obvious from the figure above, most some people who are admitted to the hospital are fairly sick on admission, starting at point (x) on the curve. We load them up with antibiotics, fluids, and vitamins, and usually by day two (y) we’ve made them better! Hooray! Everyone is happy, they go home and tell their family how great the doctors were, we go home and try to relax by drinking our livers into submission.

My concern today is patients who go from (y) to (z). You see, everyone most people some people in the hospital are sick, which means that it’s an ideal place to swap diseases. Think of it as day care, but for the elderly.

Problem is, the longer you stay, the more likely you are to catch something REALLY nasty, especially since you’ve got doctors, nurses, and techs walking around poking fingers into every orifice you knew you had, then forgetting to wash their hands, then repeating the same on the next patient.

Patients are always surprised when I try to kick them out (”but doctor, I’m still bleeding copious quantities of bright red blood from my ass!” or “but doctor, my body is rejecting my own heart and I can’t breathe without a ventilator!”)… but what they fail to realize is that if you weren’t sick when you came in, you sure as hell will be unless I can kick you out before you catch something. And let me tell you - hospital acquired illnesses are far worse than their community-based brethren. It’s the difference between 3-5 days of watery diarrhea and shitting out your own intestines†.

So please, folks. Don’t angle to stay in the hospital any longer than you absolutely have to. I know I, for one, do my best to not be there as much as possible††.

†C. Difficile in the House!
††That’s just a little joke, see.

Shadowing.

That word is enough to make a medical student cringe. You see, the vast majority of certain rotations is spent standing behind a real doctor as they see their own patients for 10 straight hours, trying as hard as possible to prevent your eyes from glazing over. The third year medical student quickly learns how to act interested in everything.

Shadowing is incredibly boring. It can be fine if you’ve got a great doc to follow - especially in specialty clinics which can be way over your head - but usually it’s the most boring thing you can do. Especially since we’re overworked and tired as it is.

End Prologue.

I’m on my outpatient medicine rotation right now, which I love… I think I’ll actually end up in this field. This month, however, the afternoons are filled with - you guessed it - shadowing clinics. Roommate and I decided we would drive out to LA and go to Magic Mountain because we’ve both got a free weekend. LA is pretty far from where I am, so I figured I’d just ditch my afternoon clinic today so we could leave early and not be driving until 4AM.

I should mention that I think every student on outpatient has skipped at least one afternoon clinic, if not more.

Normally this wouldn’t be a problem; a shadowing student is far from integral to the successful workings of a clinic. In fact, all we really ever do is slow the docs down. Usually they don’t even know we’re supposed to be there. Unfortunately, this particular clinic was staffed by an attending who is known for being a hardass. In addition, unbeknownst to me, there were also 2 patients specifically scheduled for the med student to see†.

I got paged by the Internal Medicine Clerkship Director asking me where the hell I was. Now, instead of doing the smart thing and saying that I was running late and that I’d be there in 10 minutes, for some reason I blew my common sense fuse. Instead I said that I was ditching so that I could drive to LA without being up all night.

Shitstorm.

I have absolutely no idea what the consequences are going to be, especially since when I bolted over to the clinic I was told to get out by aforementioned Hardass Attending, who looked really, really pissed off. I can see a couple ways that this will go down.

1) Clerkship Director decides to dock me a sick day, then berates me about ditching.
2) Hardass Attending calls Clerkship Director to complain, who has to apologize and then berates me about ditching††.
3) Same as #2, but with Hardass Attending telling Clerkship Director they don’t want med students at their clinic any more.

#3 would result in some pretty big problems for me. I really hope it doesn’t come to that… ‘course, this is all my own damn fault.

† This never happens, unless you’re in a rural area where they can use all the help they can get. Usually the onus is on you to ask to see a patient before the doc goes in.
††Clerkship Director also governs Clerkship Grades.