What Makes a Great Physician?

At this blog’s inception nearly five years ago, I asked myself the following question: “When you watch impressive doctors at work,
what is it that most impresses you?” In other words, what makes a great
physician? I was a third-year medical student at the time and I couldn’t
answer the question. At the beginning of training one can hardly keep up
with the incoming information, let alone consider the characteristics that
make a great physician. I liked and disliked certain doctors depending on
the way they treated residents, medical students, or patients. But beyond
kindness, their traits varied widely. During residency I have been
fortunate to work with many admirable doctors, and consequently my sample
size has grown. Seeing what I’ve seen thus far, I think
curiosity and humility are the two most impressive characteristics of a
great physician.

Wikimedia

Galen of Pergamum (AD 129–ca. 216), the Greco-Roman doctor, wrote extensively about how to
make physicians great again in his treatise That the Best Physician Is Also a Philosopher. He bemoans the lost art of medicine and the
corruption of the profession. He advocates for a temperate lifestyle,
arguing that if a physician puts virtue above wealth, he or she will be
“extremely hardworking” and will therefore have to avoid “continually eating or drinking or indulging in sex.”

A doctor must also be “a
companion of truth.” “Furthermore, he must study logical method to know how
many diseases there are, by species and by genus, and how, in each case, one
is to find out what kind of treatment is indicated.”

He continues,

So as to test from his own experience what he has
learnt from reading, he will at all costs have to make a personal
inspection of different cities: those that lie in southerly or northerly
areas, or in the land of the rising or of the setting sun. He must visit
cities that are located in valleys as well as those on heights, and cities
that use water brought in from outside as well as those that use spring
water or rainwater, or water from standing lakes or rivers.

Notice that Galen does not endorse brilliance as a required characteristic of a
physician. No, he advocates for the intelligent use of one’s faculties.
Indeed, he seems to favor curiosity about the surrounding world as a
necessary quality for a doctor.

Curiosity, a desire to discover and a desire to know, is inseparable from a
great physician. In residency we are often told by our attending physicians
that we must be “lifelong learners.” Curiosity naturally creates lifelong
learners. Medicine, after all, is not confined to what one learns in
medical school or residency. If it were, our doctors would not be very
good. One does not see every disease process in residency, one often
forgets certain things, and

the evidence

and guidelines are forever changing and improving. Thus, we must always be
looking up the latest evidence on the diseases we see.

Moreover, there isn’t always a clear diagnosis or treatment, and
physicians must scour scientific literature for the answer. When, as so
often happens, there is a diagnostic mystery, curiosity works against our
inclination towards laziness and forces us to stay on our toes, question
what we believe and why we believe it.

Curiosity also aids the clinician-researcher. Physicians since Galen’s time
have participated in various forms of research, attempting to answer
questions that have not yet been answered. For many of our predecessors
the questions were quite basic, given the general ignorance about the world
of biology. Yet there are still vast areas of medicine for which answers
are needed. The most obvious examples in the specialty of neurology concern
brain tumors or diseases like

Parkinson’s
. The lifespan for patients with certain brain tumors is a year and a half
– how does one improve treatments for these virulent neoplasms? For
Parkinson’s disease, we can only treat symptoms but cannot slow the disease
down – what treatments might reverse this pathology or at least stop it in
its tracks? Curiosity drives physician-researchers to make discoveries and
to seek answers to these questions.

But there is another characteristic, too, necessary in order to be a great
physician. The sheer volume of material one must know and understand about
medicine as well as the natural world is enormous and infinite. Because of the infinite knowledge they cannot possibly possess,
doctors must also confront this world with humility, humility about how
much one must truly know and understand in order to be great.

What was true in Galen’s life is doubly true today: There is a vast world of knowledge
in the realm of medicine. Humility, like curiosity, provides doctors with a
sense of the struggle to accumulate a vast amount of knowledge.
It helps them confront the possibility of being wrong. And
as I’ve written on this blog,

doctors are often wrong
. Humility makes us more likely to double-check ourselves, to re-examine
the patient when we’re unsure, to look things up when we feel insecure in
our diagnosis. It makes us more thorough. It urges us to listen to the
opinions of other doctors, of nurses, or even of patients.

What, then, when I watch doctors at work, most impresses me? What, then,
makes a great physician? Curiosity and humility are necessary
characteristics. There is not a single physician I look up to who does not
have both of these qualities. These alone may not be sufficient but I have
also noticed that other remarkable characteristics tend to accompany
curiosity and humility: kindness, self-discipline, intellectual rigor,
equanimity.

William Osler
Wikimedia

In his valedictory address to the University of Pennsylvania School of Medicine in 1889
(also known as the essay Aequanimitas) Dr. William Osler, one of the original four physicians at Johns Hopkins Hospital and a
legendary professor of medicine at the Hopkins medical school and later at
Oxford, discusses the quality that he thinks is most integral to being a
physician – imperturbability or equanimity. He writes:

A distressing feature in the life which you are about to enter, a feature
which will press hardly upon the finer spirits among you and ruffle their
equanimity, is the uncertainty which pertains not alone to our science and
arts but to the very hopes and fears which make us men. In seeking absolute
truth we aim at the unattainable, and must be content with finding broken
portions.

What lies behind Osler’s idea of equanimity is an acknowledgement of
uncertainty in medicine. And such an acceptance arises first from a humble
and inquisitive outlook. Curiosity and humility acknowledge this
uncertainty and the need to prepare for it, with equanimity.

How Doctors Choose a Specialty

People sometimes assume that every doctor feels a calling or has a special
skill for one area of medicine or another. But the truth is very
different for most doctors.

Old operating theater in London
Wikimedia Commons (Mike Peel, CC BY-SA 4.0)

When students begin medical school they don’t actually know what medicine entails. Maybe they’ve followed physicians around or worked in a lab. But that is completely distinct from being
in a hospital for twelve to fourteen hours a day writing notes, calling
consults, rounding on patients, operating, or delivering babies. And even
when young students do see these things, they
usually watch from afar and don’t fully understand what’s going on. The
hierarchy, the language, and the rapid exchange of information remain a
mystery.

Nevertheless, matriculating medical students still have ideas about what
specialties they want to practice. Walk around an auditorium during an
orientation and most budding physicians will say they’re interested in one
field or another. This is completely understandable; something motivates
people to apply to medical school. I thought seriously about
becoming an emergency-medicine doctor. I had worked as an EMT in New York and loved the excitement of
emergencies, the rush of adrenaline, and the range of patient presentations.
But I didn’t really know what it was like to work in an emergency room for
a twelve-hour shift.

Once medical school starts, things slowly change. As they study the
biological systems and dissect in the anatomy lab, some students realize
that they now feel dispassionate towards what they once loved. Suddenly, the eye
or the heart or the skin is not as interesting as the lungs or the brain or
the intestinal system. Granted, this is all still theoretical — it
is early, and the students have not been inside the hospital yet. But inklings
arise and ideas take hold. I enjoyed many of the educational blocks during
medical school and even had a particular affinity for hematology and

gastroenterology
, while taking a dislike, surprisingly, toward neurology (I am now a
neurology resident).

It is during the

third year of medical school
when professional ambitions take shape, as students work in the hospital and
clinic. They rotate through general surgery, psychiatry, emergency
medicine, and neurology, among other specialties, getting a quick but deep
sense about how these areas work. They participate in surgeries, clinic
appointments, and

hospital codes
. Decisions about a future specialty often form during these samplings.

But there is often much more to those decisions. I liked nearly everything during third year. I found the
operating room fascinating. You stand at the operating table and
assist the surgery residents and attending as they open up the
patient and take out parts of the intestine or the gallbladder. You
peer into a living human body in real time. You see the problem; you fix or
remove it; and then you sew the patient’s skin back together. Other
specialties are similarly awe-inspiring. On my obstetrics rotation I

delivered babies
. In the emergency room, I participated in

trauma codes
and watched the effects of

treating drug overdoses
. There is so much to marvel at in medicine that each rotation is appealing
in some way. How can a student settle on one specialty?

When faced with this impasse, another deciding factor is often
a teacher or mentor.
After all, the word “doctor” comes from the Latin verb docere, which means “to teach.” The degrees we receive when we graduate from
medical school read M.D., or Medicinae Doctor — “teacher
of medicine.” So when we speak of a

doctor’s purpose
 it is implied in the word that the purpose is not just to heal the sick but to teach the
next generation of doctors, and also one’s patients. Notice this passage from the

Hippocratic Oath
:

I swear by Apollo The Healer…. To hold my teacher in this art equal to my
own parents; to make him partner in my livelihood; when he is in need of
money to share mine with him; to consider his family as my own brothers,
and to teach them this art, if they want to learn it, without fee or
indenture; to impart precept, oral instruction, and all other instruction
to my own sons, the sons of my teacher, and to indentured pupils who have
taken the physician’s oath, but to nobody else.

Image via Flickr

These lines that deal with the doctor-student relationship come before the parts about
the doctor-patient relationship. It is one of the few professions left in this country that
still functions as an apprenticeship (somewhat similar, in a few respects, to being a Ph.D.
student under an adviser). One studies a specific topic very intensely for
an extended period of time with a group of professionals who teach you how
to do what they do. This means that who teaches you matters as much as what you’re
taught.

When I rotated through neurology, the subject area excited me, but I was particularly impressed by everything about
the doctors. They took the time to explain things to students, which in the
busy context of the hospital and clinic isn’t always a priority. They
treated patients with great respect and kindness. They knew an impressive
amount about the subject and beyond. I felt inspired. Though many
other physicians in internal medicine, pediatrics, and elsewhere were
similarly impressive, my experiences were more mixed in those departments.
This at least was my unique experience; colleagues of
mine reached different conclusions.

The physician teachers also affect the culture of each department. For example, emergency medicine doctors are frequently seen as adrenaline
junkies. They love going rock climbing, bungee jumping, racing in triathlons,
and so forth. This is not true across the board, but one likely finds a
higher proportion of people who have those hobbies in emergency medicine. Specialties fit certain personalities or interests. I found that more
neurologists shared my interests — many of them study human consciousness,
autonomy, and free will, which tie into my fascination with the humanities.

The last element that helps medical students choose a specialty is
lifestyle, or how much time one has outside of the hospital. Surgeons
seemingly live at work even when they’ve graduated from residency programs.
Surgeries can be long and tedious; unexpected disasters occur during
operations; patients need emergency surgeries; and many post-operative
patients need close monitoring to make sure there are no complications. Pediatricians, by contrast,
tend to have much more normal lifestyles. They can work in an outpatient clinic
from, say, 8 a.m. to 5 p.m. Any child with an emergency goes to the emergency room, not
to the outpatient clinic, and pediatric patients tend not to have as many
chronic, difficult-to-manage illnesses as adults (like heart disease or high blood
pressure). Pediatricians focus more on preventative measures,
such as well visits and vaccines. As a pediatrician it is much easier to keep up with
family or hobbies outside of medicine. I loved surgery, but I could not see
myself putting in the hours to do it every single day for the rest of my
life. Neurology, on the other hand, like pediatrics, often involves a more
balanced lifestyle.

And this is how we choose: subject material, mentor and teacher experiences,
department personalities, and lifestyle. But the truth is that
many of us who go into medicine could be happy in a number of specialties,
which is an important perspective to have. It means that we love, broadly,
the subject and practice of medicine, and that our curiosity about disease
processes and treatments does not start and stop in one specialized silo or
another, just as most diseases do not stop in one body part or another. It’s what makes medicine such an enthralling and difficult field.

Revisiting The House of God

Dr. Stephen Bergman, a psychiatrist, published his now-famous satirical novel The House of God under the pseudonym Samuel Shem in August 1978. The book’s protagonist, a young intern, describes the emotional and physical difficulties during the first year of residency. With more than two million copies sold, the work is something of a classic within the
medical profession.

Even in medical school, before we started our clinical rotations during our third year, some of my
friends and professors recommended I read the novel, so I borrowed it from a fellow student. I enjoyed it but couldn’t fully identify with the
characters in the story, which dealt with the hardships of residency: terrible hours, unsympathetic attending physicians, obstreperous and ornery patients, horrible deaths, and flailing personal relationships outside of the hospital because of the amount of time spent inside it. As a student, I hadn’t yet seen
these things and from the outside this all seemed unrealistic: How, I asked myself, could this even be close to the reality of a modern academic hospital?

Now that I am through my third and fourth years of medical school as well as my first year of residency I have re-read the book, and I thought it would be
interesting to reconsider my initial impression. Indeed, the novel is so much more relevant to me now. In order to illustrate this, it is worth looking at
just a few passages.

I got more and more tired, more and more caught up in the multitudinous bowel runs and lab tests. The jackhammers of the Wing of Zock had been wiggling my
ossicles for twelve hours. I hadn’t had time for breakfast, lunch, or dinner, and there was still more work to do. I hadn’t even had time for the toilet,
for each time I’d gone in, the grim beeper had routed me out. I felt discouraged, worn. (p. 41)

Though slightly hyperbolic, all this is scarily familiar to me. On some days there is so much work to do that one doesn’t really have time to sit down and
eat. Or, when one does finally have a spare moment (after 6 or 7 hours of running around), animal instincts take over and without being cognizant of
it one ravenously attacks any food available. Some of us stick granola bars in our white coat pockets to prevent this sudden and unfettered hunger attack
but even this is just enough to make us want more. Occasionally, the issue is that one forgets to eat and when we smell the trays of food being
delivered to hospital rooms during lunchtime, our intestines do somersaults, squeeze, shiver, and groan as we are reminded of our baser needs. We experience
pangs of hunger that occur throughout the day because meals, and even glasses of water if one has time for them, are far apart. I have, in multiple instances, come home at night or in the morning and stood for a moment in the kitchen while having an internal debate with myself: Am I more tired or
hungry?

And Shem’s line about the “grim beeper” made me laugh out loud. I remember twice walking into the bathroom to answer the call of nature, when suddenly the shrill sound from my pager or phone prompts me to abort the mission, walk out, and
answer the other call.

The talk was, on the part of the doctors, all medicine….

The accuracy of this is stunning. When residents get together or when we have a spare moment to chat at work, we don’t usually talk about politics or
friendships or relationships so much as we talk about medical stories. We trade tales of difficult procedures or illnesses or we tell hilarious medical jokes. Friends who spend time with us
outside of the hospital are shocked at how much we speak about work with each other. But a resident’s life revolves around the hospital. We (almost)
literally reside at the hospital and the eventful aspects of our lives usually occur in the healthcare setting. As one can see from even a quick glance at
some posts on this blog, medicine is filled with human drama, humor, sickness, death, and life. How do we avoid talking about all that in our spare time?

The House of God found it difficult to let some young terminal guy die without pain, in peace. Even though Putzel and the Runt had agreed to let the Man
With Agonal Respirations die that night, his kidney consult, a House red-hot Slurper named Mickey who’d been a football star in college, came along, went
to see the Agonal Man, roared back to us and paged the Runt STAT. Mickey was foaming at the mouth, mad as hell that his “case” was dying…. Mickey called a
cardiac arrest. From all over the House, terns and residents stormed into the room to save the Man With Agonal Respirations from a painless peaceful
death. (p. 245)

These can be traumatic moments, indeed (I have written about coding patients herehere, and here). Shem’s point is that we in the hospital sometimes do
chest compressions on patients we surely will not be able to resuscitate or, if they are resuscitated, will be dependent on a ventilator and unconscious
for the remainder of their days. Do we try to revive a 90-year-old with metastatic cancer to the spine and brain? Or do we try instead to make the patient as comfortable as possible?
From the patient’s side (and the patient’s family’s side) the difficulty, which seems insurmountable, is in accepting the end. For most physicians, like the
narrator of The House of God, the difficulty lies in cracking ribs and sending electrical shocks through someone’s body with no clear purpose. In fact, we
frequently ask families to let us make their loved ones comfortable, at least, before they pass away. But that is not always the decision that is made.
And in the passage above Shem satirically chides those who believe the best course is always to be as aggressive as possible.

Eat My Dust Eddie, being run ragged in the death-house, the MICU [Medical Intensive Care Unit], looked awful, and was talking about his previous night on
call: “I was admitting my sixth cardiac arrest and I got this call from the E.W. — Hooper, it was you — saying that there was a guy down there who’d
arrested and you were thinking of sending him to me if he survived. I hung up the phone, got down on my knees, and prayed: Please, God, kill that guy! I
was on my knees, I mean ON MY KNEES!” (p. 126) 

My colleagues and I have never wished that anyone would die. But, undoubtedly, we all identify with the feeling of being overwhelmed. When you’re exhausted
and still admitting patient after patient and trying to work them up for a new diagnosis while also taking care of other patients on the service, writing notes,
fielding pages or phone calls from nurses, drawing blood, and doing CPR, there are moments when it feels as if there is no more time or effort left to give.
You are working with rope with no slack or trying desperately to tread water. This is especially true in a place like the Intensive Care Unit, where patients are sicker
and require closer monitoring. During those moments, we beseech the hospital gods: “please, no more admissions, please no more.” Or, “please don’t let
anyone get sicker than they are.” It’s not every day one feels this way, but it is often enough that the sentiment is familiar.

*   *   *

When The House of God was first published it was not received well by Dr. Bergman’s colleagues and peers. As he tells it,

… my book The House of God enraged many among the older
generation of doctors. I was maligned and disliked. The book was censored by medical school deans, who often kept me from speaking at their schools. None
of it really bothered me, though. I was secure in the understanding that all I had done was tell the truth about medical training.

Thus, the book is not only a brilliant and witty piece of satirical literature, it is also a “fiction of resistance,” as Bergman describes it. Its most sinister and clueless
characters are the ones in charge. And in many cases their worship at the altar of medicine and science damages their relationships with patients,
residents, or each other.

Much has been written about this aspect of the book in recent years: Dr. Howard Brody of the University of Texas Medical Branch

wrote about its relevance in the American Medical Association’s Journal of Ethics in 2011
. Dr. Suzanne Koven, a primary care physician,

interviewed Dr. Bergman about the book for the Boston Globe in 2013
. Dr. Howard Markel, a professor of pediatrics, psychiatry, and the history of medicine at the University of Michigan, discussed the book in a piece for the New York Times in 2009.

The reason for this interest may have something to do with a story Bergman tells in his own 2012 piece for The Atlantic:

And then one day I got a letter forwarded from my publisher, which included the line:
“I’m on call in a V.A. Hospital in Tulsa, and if it weren’t for your book I’d kill myself.”
I realized that I could be helpful to doctors who were going through the brutality of training. And so I began what has turned out to be a 35-year odyssey
of speaking out, around the world, about resisting the inhumanity of medical training.

But the culture in medicine has changed dramatically since this book was written. Institutions are far more humane than they once were. Nevertheless, what we see and how much we need to see cannot change. Doctors ought to be exposed to a wide range of pathology; they
must be exposed to death. This is how one learns to be a great doctor, to diagnose obscure diseases, to treat common diseases successfully, and to save
lives during a hectic code in the hospital.

No matter how authority figures treat residents, Bergman’s book will always be precious to future generations of doctors. Like any great novel it identifies common yet significant human experiences. The author tells us, as it were, that “yes, I know
exactly what this is like and I laughed at the same things you did. I made the same mistakes. I had the same
difficulties.” Such commiseration ameliorates that unsettling feeling residents experience: the feeling that the hospital is a rabbit hole
that spirals into a detached and harrowing yet hilarious world. And, because of The House of God, there will always be a shared understanding
among residents and readers of the triumphs and tragedies accompanied by this feeling.

A Day in the Life, Part 2

This post continues my description in the last one of a day in the life of a medical student on rotation, where I’ve left off at lunchtime of an inpatient service day.

During the afternoon, the work of executing plans continues. If the team discharges a patient, that patient needs a follow-up appointment in clinic to make
sure there are no complications from the hospital visit. We call up the outpatient clinics and schedule patients for their next appointments. In other
cases, we need a patient’s hospital records from his or her previous visit to another hospital. Because electronic health records are usually closed within
a hospital system, we have to request that other hospitals fax us medical information. This is a rate-limiting factor in getting complete access to lab and
imaging results, which are integral to patient care. For instance, if a patient comes in with a severe headache and another hospital performed a CT scan of
his head, access to that scan may be essential to ruling out a diagnosis of something serious, like a brain tumor or infection. And if we can’t get
the images from the other hospital we may have to do one at our hospital. This is, undoubtedly, one of the major weaknesses of a non-universal electronic
health record system.

The medical team may also discharge a patient to a skilled nursing facility (SNF) or an old-age home, in which case the facility needs documentation
regarding what further care is needed. Some patients do not have anywhere to go after the hospital; some abuse alcohol or drugs and must go to a rehab
program; some can’t pay for the oxygen they need at home or medications for HIV; others started taking a blood thinner called warfarin and need to schedule appointments at a lab to get blood levels of this medication checked. To
deal with all this, the residents, attending, pharmacists, nurses, and social workers all coordinate with each other and with governmental and private
organizations to get the patient where he or she needs to be and what he or she needs in order to stay healthy. The healthcare team takes on this Sisyphean
task with varied success. Given the number of factors involved in this transition, one of which is whether the patient takes his or her medication, the
result is not always ideal. I’ll write more about this later.

Additionally, the residents and attending physician sometimes admit new patients to the hospital during the afternoons from smaller hospitals in the
community. Community hospitals are not always capable of caring for patients with a rare tumor or disease, while academic medical centers, which are
attached to medical schools, have more physicians who specialize in and research rare disorders. For example, a patient having seizures that cannot be controlled with first or second-line medications is sent
over to an academic institution where neurologists experienced in handling refractory seizures can care for the patient.

The medical team may also admit a patient from the Emergency Department (ED) for a full diagnostic workup and treatment of an acute or chronic disease. For instance, a patient
with worsening Chronic Obstructive Pulmonary Disease (COPD) needs temporary
high-potency medications for a few days before going back home. Some patients with an exacerbation of this disease need constant monitoring so they don’t
experience respiratory failure. Clearly, then, the afternoons can get busy, especially if the residents have to finish their notes.

At 6 p.m., the night intern arrives and receives checkout from the day team: The day intern runs through a list with the night intern, describing the new
admissions to the hospital service, the events over the course of the day for each patient, and which lab and imaging results the night intern needs to
follow.

Image via Shutterstock

Outpatient and the ED

The time that we spend in a doctor’s office — on our outpatient weeks — is a lot less hectic. Whether we are in family medicine, pediatrics, or obstetrics/gynecology clinic, we arrive at 8 a.m., which
gives us time to exercise in the morning or stay up a bit later at night. The residents arrive at the same time. We look at the clinic schedule for the
day on the electronic health system and begin to read old notes in the electronic health record to get ourselves up to date with the latest medical information
on each patient.

When patients arrive, the medical student goes in first to interview a patient and do a focused physical exam, after which the student reports his findings and his plan to the resident, just like we do in the ED. The attending and the
resident then see the patient and come up with a tailored plan for how to proceed. We have an hour for lunch at noon and then come back from 1 p.m. to 5 p.m. (This is similar to our ED
shifts, since they are both eight hours — except of course our ED shifts are sometimes late at night or overnight, and there are no scheduled meal breaks during an ED shift.)

After our days finish, we are expected to do research on a disease process we saw during the day. If a patient comes in with pneumonia, we read up on the
common causes of pneumonia and the various treatments available for it. We also study for our shelf exam, which is a national multiple-choice test that we must pass
after each third-year rotation. At the end of pediatrics, for instance, the shelf exam tests us on pediatric illnesses and treatments. These tests are difficult
and so we frequently study from various third-party review resources —

Kaplan
, UWorld, PreTest, Case Files, and others. A whole industry is built around these shelf exams, which
eventually culminate in a nine-hour, eight-section national licensing exam called STEP 2 CK. This comprehensive exam
tests basic clinical knowledge at the end of third year. So on a day-to-day basis we not only worry about learning how to deal with patients and their
illnesses but we also study for our exams, which is a requirement that ensures we know the important information involved in our daily practice.

A Day in the Life, Part 1

My editors here at The New Atlantis suggested I write about what a day is like for me and other members of the medical team. What exactly (aside from
rounding) do we do all day? When do we have to be in? When do we leave? What goes on when we’re not rounding?

We can divide the third year of medical school into three distinct categories of rotations. There are inpatient weeks (hospital work), outpatient weeks
(doctor’s office work), and the Emergency Department, or ED. The roles differ as do the schedules. I have already described a bit about how the ED works here. The hospital is for patients who need urgent medical attention or
medical procedures. If a patient is having a heart attack, for instance, a cardiologist in the hospital will make sure the patient does not suffer
complications from the disease process. Outpatient work, by contrast, involves less urgent medical problems, like adjusting blood pressure medications or prescribing antibiotics for an ear infection. Let me take you through a day on inpatient and outpatient medicine.

Inpatient

On an inpatient service the interns arrive at approximately 6 a.m. or, if on a surgical service, at 5:30 a.m., and print out a patient list from the electronic
health record. This list of patients contains the patient names, chief complaints, possible diagnoses, ages, and other basic information of the patients we
need to see. It contains a summary of tests and test results as well. It may seem a bit silly that physicians need a reminder about which patients they are
taking care of; however, the hospital experiences quick turnover. A patient may be present for only a couple of days before leaving. Then, a new patient
with a new history and a new problem takes his or her place. Additionally, when there are sixteen patients on the list it is difficult to keep up with
every story.

Medical students arrive shortly after the interns (the residents are a bit like our supervisors, letting us know when we can leave and when we ought to
come in). Given how early in the day we usually have to be in, there is little time in the morning to do anything but eat a quick breakfast while
bleary-eyed before driving to the hospital in the dark. If we’re there early enough, we receive checkout from the night intern. The night intern goes
through each patient on the list and discusses the latest news on each patient. Did the patient vomit? Did he or she have trouble breathing? What
interventions, tests, or treatments were done? Additionally, if the night intern admitted new patients overnight, what is the story behind the hospital
admission? These questions are vital to the care of each patient. If the day resident does not know, for example, that a patient was having trouble
breathing or received an imaging study then the resident does not know to look at the results of that study, potentially missing a life-threatening problem
like a collapsed lung or a heart attack. In an ideal world, the transition between resident shifts is so seamless that it is as if the day resident took
care of or admitted patients during the night.

Subsequently, the interns assign medical students to “follow” one, two, or three patients (depending on how far along we are during our third year). Following a patient
means knowing the vital signs daily and keeping up with the results of x-rays, CT scans, and lab tests. It also means we come up with a plan for that
patient’s care and propose it to the attending and residents. In truth, the residents and attendings already know what they are going to do for the patient
and our proposals are merely an exercise for our own edification.

After these assignments, we go through the chart on the electronic health record and read about the patient’s history. We read the night intern’s note on
the patient and we look at the labs (tests) that the intern ordered. These notes give us a sense of what the residents or attendings thought the patient had and
needed. For example, if the patient came into the ED with a fever and a cough, the notes will usually mention a workup and treatment for a possible pneumonia, or lung infection (which includes a chest x-ray, sputum culture, and
empiric antibiotics). More importantly, students and residents look at the vital signs of the
patients we follow. These indicate if the patient needs immediate treatment. Is the blood pressure too low with a fast heart rate and a high body
temperature? This indicates a possible blood infection and we take blood cultures and administer antibiotics.

Despite the fact that the sun has not yet peeked through the hospital windows, we subsequently visit patients in their rooms to do a physical exam. We look
at new rashes that patients have, listen to hearts and lungs with stethoscopes and perform neurological exams. We target our exam at the patient’s
presenting illness. For a patient with pneumonia, we listen closely to the patient’s lungs for abnormal breathing sounds due to the infection. All this, of
course, entails waking the patient up. And since residents, appropriately, will come in after us to make sure that we have done the physical exam correctly
and that the patient is in no distress, we unfortunately wake the patient up at least twice during the early morning hours. This is separate from the
instances where the nurses wake the patient up to draw blood for morning labs. Such is one difficulty of being a patient at a teaching hospital, something
I will discuss in future posts.

Image via Shutterstock

Once we’re finished seeing the patients, we have a little bit of time left before rounds start at 8 a.m. We look up information about the illnesses our patients have. We also write down the information we will need to present the patient to the attending physician on rounds. I’ve written a bit about
patient presentations in this post, but in sum,
our presentations report the relevant medical information and treatment plan in an organized and concise matter.

At 8 a.m., the attending arrives and we round on patients. Aside from the few patient presentation(s) we do for the attending we remain silent and watch and
learn as I’ve described previously. Once we finish rounding
we go over the patient list in the physician work room. We make sure that we all agree on the plans for each patient for the rest of the day. Some patients
need to leave the hospital. Some need more IV fluids or medications. And some need an imaging study or a blood test.

After we’ve confirmed all of this, the residents write “notes” about each patient for the electronic health record. A note is similar in format to a patient
presentation. It contains a brief history of the patient’s chief complaint and illness as well as the blood test results, imaging test results, diagnosis,
past medical history, and past surgical history, as well as the treatment plan for the patient. These notes, though incredibly time-consuming, serve a
valuable purpose. First, legally, the note can help protect a physician from future lawsuits. The note documents a physician’s train of thought and
actions. It justifies the tests and treatments which patients receive in the hospital. Second, it is used for billing purposes by documenting what was done
for the patient. And third, when the patient goes for a follow-up appointment with another physician in clinic, the note acts as a standardized form of
communication to update the clinician on what was done in the hospital.

At lunchtime, medical students usually receive a lecture from a physician in the rotation. In pediatrics, for instance, we may listen to a lecture on
pediatric respiratory complaints from a pediatrician. Meanwhile, the residents remain in the workroom or, if they’ve finished with their notes, they can
grab a quick bite to eat in the cafeteria. Sometimes, though, the residents are swamped. They carry around pagers or phones, and nurses and other physicians
page or call throughout the day with questions about specific patients. A patient may get a headache or feel nauseous and the nurse may page the resident
to ask if it’s okay to give pain medication or antiemetics (medication for nausea or vomiting). Given
that there are a limited number of residents, if multiple patients fall extremely ill and need medications, it can be difficult for the residents to
respond to other more minor complaints. A cardiac arrest on the floor, for example, may prevent the resident from ordering pain medication for a patient
with a headache.

More on a day in the life, in a bit…

Residents and Rounds

Doctors practice “grand rounds,” ca. 1920s.
(National Library of Medicine)

This post is meant to provide a bit of background about how the day works and how a medical team functions so the references I make in future posts are clear. Let’s begin with the team. Nearly every medical team at an academic hospital consists of an attending physician, residents, interns, and medical school students. While these terms might sound familiar to anyone who has watched medical dramas on TV, it’s likely that most people don’t know what they mean. The attending physician is a bit like a tenured professor. He or she has the most experience and training in the operating room and the clinic, and has graduated from medical school, residency, and, in most cases, a fellowship program.

The residents, having graduated from medical school, are also physicians but, being less experienced, are “attendings-in-training,” learning the craft of a specialty via instruction from an attending physician. Residents are classified by the number of years they’ve spent in training, and different specialties will require a shorter or longer residency: there are chief residents (the most experienced residents), fourth-year residents, third-year residents, and so forth. Then there are the interns, physicians who have just finished medical school and are spending their first year out of school rotating through different specialties, learning how to enter orders for medications, writing progress notes on patient care and discharge notes to release patients from the hospital, and responding to immediate issues that arise during the course of the day. To do this an intern must know each patient in order to respond to questions about treatment from the patient and nurses.

Third-year medical students comprise the lowest rung of this ladder. We have little to contribute and plenty to learn. Frequently, we are assigned to follow a few patients and come to know as much as we possibly can about them. Once we know everything about our patients, it will be easier for us to think about what is most important regarding each patient’s care. We learn to pay attention to important details.

This team hierarchy, though it may seem stilted, is actually integral to the process of rounds, where the medical team visits each patient in its care. Rounding provides an opportunity for the healthcare team to speak with patients about how they are doing, to look at and physically examine them. The physical part of the exam is fundamental to healthcare. The abdomen, for example, can feel distended or stiff if there is a certain pathological problem, such as a bowel obstruction. Only by palpating — touching the patient’s body — can we know this. One cannot assess a patient’s progress until one examines a patient.

There are two official times to round during the day. One is immediately upon arrival at the hospital without the attending physician. This involves residents and medical students. And the other is with the attending physician later in the morning. While shuffling between different floors and patients, the hierarchy remains eminently clear. The attending physician leads the charge and behind him or her follows, in order of experience, everyone else: the third-year, the second-year, then the interns, then the medical students. There are usually about eight of us rounding together; to an untrained observer, we might look like the motorcade of a foreign diplomat. We all squeeze into each patient’s hospital room as the attending physician conducts the interview with the patient, assesses the patient, and tells the patient what the team’s plan is over the course of the day: Will a new medication be prescribed? Will the patient finally be able to eat food? Can the patient only drink liquids? As the attending explains this to the patient, one of the interns runs over to the computer inside the patient’s room and enters in the new medication orders or dietary orders. And on to the next patient. Over the course of the day, the new orders are confirmed and reconfirmed with the attending and upper level residents,

This daily pattern of rounding is actually a tradition as old as the American hospital system itself. In earlier days, there was a system of apprenticeship. So, if you wanted to be a physician in late-eighteenth-century America, you would be apprenticed to a doctor who would teach you all that you needed to know. You would then probably be offered a partnership with your teacher. But as the hospital and medical school system took root in the early nineteenth century, students pursued learning opportunities in hospitals in order to receive a more thorough practical education en masse. Individual physicians, after all, had very little time to apprentice aspiring doctors, and frequently the knowledge you received depended solely on one person. In order to teach medicine, hospitals created special programs where students would, as they do today, pay a fee for a basic science education (meaning anatomy, physiology, and pathology) and, eventually, a clinical one as well. Students rounded with residents (also known as house staff) and attendings in order to receive this practical experience in patient care. One description of rounds in Massachusetts General Hospital by Dr. James C. White in the 1850s sounds eerily familiar to me:

[The attending physicians] pass from bed to bed in the large wards, the students following. The house [officer] narrates any incidents in each patient’s condition during the previous twenty-four hours; the physician asks questions, makes the necessary explanations, and directs treatment. Over new and interesting questions much time is spent…. Students have nothing to do with the investigation of cases; they have only to look and listen.

My theory about this process as an educational tool is that it is suited to the role of each member of the team. The upper-level resident should be learning how to dictate orders and take charge of the team because soon he or she will be in that position. The attending, who knows this process well, educates the upper-level resident on whether the plan of care is correct and guides the fourth-year or chief resident. The mid-level resident follows closely on the heels of the upper level because he or she will soon occupy that position. And the interns need to learn how to manage patient care on a detailed level, writing notes and orders to improve at compounding a ton of information into a paragraph or two and assessing doses and units of medications.

And we, the medical students, observe and listen and ask questions when we can. Our purpose is to learn the language by observing patterns in patient care and disease. Thus far, it’s difficult to tell whether this strategy is working; it sometimes feels like I am back in French class on the very first day, listening to a language I’ve never heard before regarding dosages, plans of care, boluses, IV infusion rates, and so forth. But it is also comforting to know that this process has worked for more than a century and a half, and so perhaps we third-year medical students are right where we should be.