How does one become a doctor?

Well, how was your week? It seems like this week went quickly- the end of my CCM rotation (I spent the last month in the transplant ICU- learning alot, working with great doctors, really enjoyed it.) Monday I start my Medicine AI- finally! So what does that mean? Well, since I would like to use part of this blog to explain the process of medical school, this seems like a good time to start! I have learned over the past 4 years that MANY people have no idea what it takes to become a doctor, how one would ever go about teacihng ALL that a dr needs to know... and although there are books out there about the experience of residency, not many cover the subject of medical school. So let me give a very brief overview, and we'll explore various topics in detail in coming blogs. But for today, an overview and then the subject of the AI. Ok- so medical school is a 4 year process. You must have completed a college degree before starting (with a few rare exceptions). So when someone is "pre-med" they are in college and planning to go on to med school (MANY change their minds). When one says they are in med school, they are no longer pre-med, they are "true med"- in grad school after college, literally on their way to becoming a doctor. A lot of people I know think I am "pre-med" because I look young, they didn't know me when I was in college, and the lingo is totally confusing! But if you ever meet a "med student"- please know that they have already done college and definitely chosen medicine as their career, and more significantly, they are working MUCH harder than any college student- that's why we sometimes bristle when we get called "pre-med." I'm doing a LOT more work than pre-med! Ok, off my soap box! You apply, you get in (a crazy process that I'm not doing justice to at ALL but I'll talk about it another time)... the first 2 years (with a few notable exceptions) are "lecture years." Most schools involve some amount of patient contact, small group activities, etc, but for the most part, this is similar to college. Except- so as not to contradict myself- it is MUCH harder. My mom was once told by a doctor that medical school is like drinking from a fire hydrant- the material comes at you SOOO fast you can't help but feel overwhelmed and yes, it IS impossible to keep up. Much of the first 2 years is all about learning how to learn effectively in a setting where you will never know enough! Anyway, the fire hydrant image has become a theme in my conversations with my mom over the past several years- it's a very good analogy. Just as you're getting comfortable with this new pace or memorizing and test-taking, 2nd yr ends and it's time for USMLE Step 1. If you ever talk to a 2nd or 4th yr med student, you will hear them mention "the boards." I'll cover this in more detail at some point too, but for now know that it's the licensing exam for the US to say "we're qualified to be doctors"- just like the bar exam for lawyers or the RN exam for nurses. But for medicine, there are 3 parts. Part one- or "step 1" is taken at the end of 2nd yr; step 2 (which actually has 2 parts) is taken during 4th year. And Step 3 is taken after your 1st year of residency (and it's NOT the last test you take either...) After the huge milestone of step 1, you move on to "the clinical years." For 3rd and 4th yr, a med student spends most of their time with patients. With the exception of a few hours a week, lectures are a thing of the past. Even the tests are less frequent and usually (not always) less stressful. You are literally doing what you want to do- being a doctor- except that you're learning much more than you're doing, and throughout the years of med school and residency you gradually acquire more and more competence and independence. During 4th year you're back to the "the boards" (step 2) as well as applying for residency- but first you have to choose your specialty! (Another future subject will be "residency" vs "fellowship" vs "internship" and specialties vs primary care vs subspecialties... subjects that really are pertinent to any patient but explained to very few!) In either case, one of the requirements of 4th yr to prepare for applying to residency is the AI, or "acting internship" (hence AI), at some schools called a "sub-internship" (usually shortened to "sub-i")- It's a month in which you function as if you were already in residency. That means you take more responsibility for your patients, work longer hours, and get to teach the 3rd yr medical students-it's your first step up the medical hierarchy! Hmm... I want to explain what it is I actually DO all day with patients (a question I get asked a LOT), but I think I need to explain more of the hierarchy first. The medical student (1st-3rd yr) is the bottom of the totem pole- the one who knows (almost) nothing and has (almost) no experience. You are typically the information gatherer, there to perform mindless tasks and absorb information like a sponge (ok, maybe we do a little more than that, but not always!) the next tiny step up the ladder is the 4th year med student or Acting Intern. This is the person who isn't really a doctor but has learned enough to sort of practice being a doctor, with a lot of guidance. I'll describe that in more detail in a minute. The next step up- a BIG step- is the "intern" or 1st-year resident. I have to stop here and explain the terminology- probably the most confusing in the whole medical system. Traditionally, on the job training after medical school was called "internship" and the people in training were interns. Over time, however, medicine has gotten more complicated and so has training. So that "apprenticeship time" after med school is typically called residency and lasts for 3-5 years depending on the specialty. In SOME specialties, the 1st year of residency still resembles the traditional "internship" and thus 1st year residents are sometimes called interns, and the terms intern/resident and internship/residency get very confused. But for all intents and purposes, they're all the same. After residency, if you want to subspecialize (say, a pediatrician who wants to focus on cardiology) you can do further training called fellowship. In any academic center (where there are med students/residents +/or fellows in training), the doctor who is DONE with all their training is called the "attending." Ok, so back to the hierarchy. The med student, the AI, the first yr resident or intern- this is the person who does MOST of the work, sees MOST of the patients, and also teaches the med students/AI's. This is when you really learn based on massive amounts of experience. This is when the infamous long hours kick in... currently there are limits, so IF a program follows them, you can't work more than 80 hrs/wk, and you can't work more than 30 hrs/shift. Yes, this is an improvement- residencies like surgery used to commonly work 120 hrs/wk [go ahead and calculate- that leaves 48 hrs/wk for sleep, cooking/cleaning/shopping, studying and "relaxation" or a "social life." (If you get the recommended 8 hrs of sleep/night, that would be 56 hrs/wk).... you can see why they the limit of 80 is such an improvement!] Ok, so the med student eventually becomes an AI, then makes the big jump to intern/1st-yr-resident, then in your 2nd and 3rd (and sometimes more) years of residency, you begin to supervise- you're pseudo-in-charge of the interns, AI's and med students on your team, in charge of being sure they are taking proper care of the patients, and you're also responsible for teaching them all. But you're only "pseudo" in charge- the attending is the one who is really responsible (if a mistake happens, it's the attending who has to answer, not the trainees under them). So naturally, the next step up the ladder from resident is... chief resident or fellow! A chief resident is someone who has finished residency but takes a year off to teach- their main job is teaching the residents and med students. So they don'tt really oversee patient care, but they are a step above the residents as far as knowledge and experience. Then there are the fellows- the ones who are subspecializing and doing further training after residency. Not all teams will have them, but if they do, they are actually supervising the residents/students and they are still being supervised by the attendings, but they do have a lot more autonomy. And yes, the FINAL rung is attending. Well, sort of. Because then you have attendings with different faculty status (just like the different levels of professor in a university), and all of the attendings within a department (like orthopedic surgery, for example) answer to the chief of the department. But the hierarchy "on the floor"- the hoarde of white coats caring for the patient in a teaching hospital- is composed of students, residents, sometimes a fellow and an occasionally-seen attending! So where was I going with all that? Oh yes, the AI. My first step up the ladder, finally! What will I be doing as an AI? Well, I get to the hospital early (~7, some specialties start earlier, a FEW start later). I get information from whoever was there overnight on what has happened with my patients, and learn if I have any new patients. Then I go "see" my patients- that means I wake them up from what is probably the only sleep they've gotten all night and ask them how they feel and expect a meaningful answer, something other than "tired!" Seriously, I find out how they feel, if they have any questions/complaints. I do a quick exam (heart/lungs/abdomen and anything related the why they are there), then go to the nurse, the chart, the computer, etc to get all the information on their vital signs, labs, tests, etc. Then I "write a note"- summarize everything I've just learned, and develop a "plan for the day" (things like ordering a new medicine or new test or sending them home). Then I meet with my team- the other students and residents and sometimes the attending- and we go around and tell each other about our patients, so the resident in charge (the 2nd or 3rd yr resident) can tell us if we missed anything, if our plan needs to be changed at all, and so we can learn from the other patients that we're not following ourselves. Then we do our "work"- this could mean procedures like drawing blood, making phone calls to other specialists or to the family, writing orders for a patient going home, etc. In the afternoon we "round" again- look up new test results, check in on our patients, and eventually sign out- tell the person who will be there overnight what's going on with our patients, what to watch out for, what to do if such and such happens, etc. That's a typical day- unless you're "on call" which means YOU are the one who will be there overnight and everyone else signs out to you and you stay up and take care of all the patients who get sick overnight, etc. I also left out new admissions- there's a complicated system for who takes which patients but generally each day you are likely to get new patients assigned for you to follow. When you get a new patient, you do a detailed exam, like if you went to the doctor for a yearly check-up, and you get LOTS of information about them, not just how they've felt overnight. And when you're done, you still write it all in a note and tell the resident and attending about them and write orders for meds, tests, etc... I think one of the reasons I enjoy it is because it's so diverse. I talk to patients, I talk to other doctors, I examine patients, I write orders, I read xrays and interpret lab results, I research diseases I don't know much about, I do procedures- it's awesome! Well, when you're not struggling to stay awake, that is. Ok, as I wrote all that, I realized one other topic I will have to cover at some point- medical jargon! Through the arduous process of medical school, we truly learn a new language, and it becomes so engrained that it's hard to remember "English"- and if you have ever been a patient, you'll appreciate a bit of a translation! So all that and more to come... but right now my arm needs a break from typing! This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.